Provider Demographics
NPI:1215929344
Name:TROUT, CHARLES A (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:TROUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1444 WESTERN AVENUE
Practice Address - Street 2:SUITE B-2
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3458
Practice Address - Country:US
Practice Address - Phone:518-458-8014
Practice Address - Fax:518-533-6714
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147030207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01160012Medicaid
NYRA2990Medicare PIN
NY01160012Medicaid