Provider Demographics
NPI:1881617645
Name:PRENDERGAST, THOMAS W (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:PRENDERGAST
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 1:2005 FAIRVIEW AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042-3915
Mailing Address - Country:US
Mailing Address - Phone:610-923-5200
Mailing Address - Fax:610-923-5272
Practice Address - Street 1:2005 FAIRVIEW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-3915
Practice Address - Country:US
Practice Address - Phone:610-923-5200
Practice Address - Fax:610-923-5272
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06864200208G00000X, 204F00000X
MO2015010868208G00000X
PAMD064702L208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7496303Medicaid
NJP007151069OtherRR MCR
NJ7496303Medicaid
NJP007151069OtherRR MCR
NJ023273NAHMedicare PIN
A66261Medicare UPIN
023273Medicare PIN
NJ023273BT5Medicare PIN