Provider Demographics
NPI:1427040567
Name:TREVORROW, THOMAS C
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:TREVORROW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 PROFESSIONAL CTR
Mailing Address - Street 2:1265 WAYNE AVENUE, SUITE 203
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3501
Mailing Address - Country:US
Mailing Address - Phone:724-463-0286
Mailing Address - Fax:724-463-3542
Practice Address - Street 1:119 PROFESSIONAL CTR
Practice Address - Street 2:1265 WAYNE AVENUE, SUITE 203
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3501
Practice Address - Country:US
Practice Address - Phone:724-463-0286
Practice Address - Fax:724-463-3542
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2007-08-27
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
PAMD049389L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1040831OtherGATEWAY PROVIDER
PA735637OtherBLUE SHIELD PROVIDER
PA72340OtherMED PLUS
PA735637-L3DOtherBLUE SHIELD PROVIDER
PA0014147820002OtherMEDICAL ASSISTANCE PROVID
PAF52523Medicare UPIN
PA735637-L3DMedicare ID - Type UnspecifiedMEDICARE PROVIDER