Provider Demographics
NPI:1245296524
Name:TRUSSELL, J C (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:C
Last Name:TRUSSELL
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 1:750 EAST ADAMS STREET
Mailing Address - Street 2:UPSTATE UNIVERSITY HOSPITAL
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-464-6031
Mailing Address - Fax:315-464-6117
Practice Address - Street 1:750 EAST ADAMS STREET
Practice Address - Street 2:UPSTATE UNIVERSITY HOSPITAL
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-6031
Practice Address - Fax:315-464-6117
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418317208800000X
NY253896208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03124494Medicaid
PA0018902490001Medicaid
NYJ400005987Medicare PIN
PA55859Medicare ID - Type Unspecified
H57769Medicare UPIN