Trevor Elan Black, D.P.M.

Primary specialty

Foot & Ankle Surgery PodiatristTaxonomy code 213ES0103X

License

3381305 Issued in ID

Practice address

623 S Main St Ste 1
Moscow, ID 83843-3042

Phone

(208) 882-2011

NPI assigned

Apr 15, 2013

Last updated

Sep 22, 2026By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Podiatry

Education

Other, 2013

Medicare assignment

May accept Medicare assignment

Group practices

Matrix Rehabilitation-Georgia IncGroup PAC ID 2567379498, shared by 4 NPIs, 40 clinicians

Physiotherapy Associates IncGroup PAC ID 3577470442, shared by 50 NPIs, 1,432 clinicians

The Southeast Permanente Medical GroupGroup PAC ID 6204829013, 823 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Saint Joseph's Hospital of Atlanta, Inc Hospital, Atlanta, GA, CCN 110082

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• The Southeast Permanente Medical Group

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1245266956
  Medicare reassignment Care Compare group NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Saint Josephs Hospital of Atlanta Inc

  • General Acute Care Hospital
  • Atlanta, GA
  • NPI 1679664395
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1365984000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1790035200000",
    "number": "1861835308",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 8007",
            "city": "MOSCOW",
            "state": "ID",
            "postal_code": "838430507"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "623 S MAIN ST STE 1",
            "city": "MOSCOW",
            "state": "ID",
            "postal_code": "838433042",
            "telephone_number": "208-882-2011"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "700 S Main St",
            "address_purpose": "LOCATION",
            "city": "Moscow",
            "state": "ID",
            "postal_code": "838433046",
            "country_code": "US",
            "telephone_number": "208-882-4511",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "20 Glenlake Pkwy",
            "address_2": "Kaiser Permanente Glenlake Medical Center",
            "address_purpose": "LOCATION",
            "city": "Atlanta",
            "state": "GA",
            "postal_code": "303283473",
            "country_code": "US",
            "telephone_number": "818-326-1058",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLACK",
        "first_name": "TREVOR",
        "middle_name": "ELAN",
        "name_prefix": "Mr.",
        "credential": "D.P.M.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-04-15",
        "last_updated": "2026-09-22",
        "certification_date": "2026-09-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "ID",
            "license": "3381305",
            "primary": true
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "GA",
            "license": "POD001289",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepiceast.kp.org:14430/Interconnect-prodgam/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "20 Glenlake Pkwy",
            "city": "Atlanta",
            "state": "GA",
            "country_code": "US",
            "postal_code": "303283473",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Madison Nicole Bittle
• BK Inc. (Moscow Mountain Sport and Physical Therapy)
• Erik Blaker
• Kimberley D Blewett, D.O.
• Bloomin Family Therapy, LLC
• Bluesky Dental
• Elizabeth Bonanni, ATC

• Foot & Ankle Surgery Podiatrist in Moscow, ID
• Providers in Moscow, ID by specialty
• Foot & Ankle Surgery Podiatrist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 22, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.