Provider Demographics
NPI:1972740652
Name:THOMAS C TREVORROW
Entity type:Organization
Organization Name:THOMAS C TREVORROW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:TREVORROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-463-0286
Mailing Address - Street 1:119 PROFESSIONAL CTR
Mailing Address - Street 2:1265 WAYNE AVENUE, STE. 203
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3586
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, STE. 203
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3586
Practice Address - Country:US
Practice Address - Phone:724-463-0286
Practice Address - Fax:724-463-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049389L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007456850004Medicaid
PR735637OtherBLUE SHIELD PROVIDER
PA735637-L3DOtherBLUESHIELD PROVIDER
PA111710OtherHIGHMARK GROUP
PA1007456850004Medicaid