Provider Demographics
NPI:1639130503
Name:FREY, THOMAS B (PAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:FREY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MYERSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17067-2328
Mailing Address - Country:US
Mailing Address - Phone:717-866-5755
Mailing Address - Fax:717-866-7120
Practice Address - Street 1:431 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MYERSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17067-2328
Practice Address - Country:US
Practice Address - Phone:717-866-5755
Practice Address - Fax:717-866-7120
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50121162OtherCAPITAL BLUE CROSS
PA50054853OtherCAPITAL BLUE CROSS
PAP00652648OtherRAILROAD MEDICARE
PA120975KAGMedicare PIN
PA324860SGTMedicare PIN
PAP00652648OtherRAILROAD MEDICARE
PA071476Medicare ID - Type Unspecified
PA50121162OtherCAPITAL BLUE CROSS