1548513104 NPI number — TREVOR C. FARNSWORTH PA

Table of content: TREVOR C. FARNSWORTH PA (NPI 1548513104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548513104 NPI number — TREVOR C. FARNSWORTH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARNSWORTH
Provider First Name:
TREVOR
Provider Middle Name:
C.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548513104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 SALINA MEADOWS PKWY
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-646-2000
Provider Business Mailing Address Fax Number:
315-464-2010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
739 IRVING AVE
Provider Second Line Business Practice Location Address:
STE 640
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-464-6255
Provider Business Practice Location Address Fax Number:
315-464-6251
Provider Enumeration Date:
10/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  016124 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03512512 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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