Provider Demographics
NPI:1649264052
Name:TREDENNICK, TREVOR D (MD)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:D
Last Name:TREDENNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2715
Mailing Address - Country:US
Mailing Address - Phone:208-365-3561
Mailing Address - Fax:
Practice Address - Street 1:1202 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2715
Practice Address - Country:US
Practice Address - Phone:208-365-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112632207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8420713Medicaid
IL036-112632Medicaid
ILH61083Medicare UPIN
IL036-112632Medicaid
WA8852296Medicare PIN