1538160742 NPI number — KRISHNAPILLAI THAVARAJAH MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538160742 NPI number — KRISHNAPILLAI THAVARAJAH MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

THAVARAJAH

Provider First Name:

KRISHNAPILLAI

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1538160742

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/30/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 77000 DEPT 771255

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DETROIT

Provider Business Mailing Address State Name:

MI

Provider Business Mailing Address Postal Code:

48277-2000

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

313-271-3000

Provider Business Mailing Address Fax Number:

313-271-3003

Provider First Line Business Practice Location Address:

16407 SOUTHFIELD RD

Provider Second Line Business Practice Location Address:

STE A

Provider Business Practice Location Address City Name:

ALLEN PARK

Provider Business Practice Location Address State Name:

MI

Provider Business Practice Location Address Postal Code:

48101-2571

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

313-271-3000

Provider Business Practice Location Address Fax Number:

313-271-3003

Provider Enumeration Date:

08/10/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RN0300X , with the licence number:  A301033660 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: G02484 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 103192 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 4098 . This is a "CAPE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 108137 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 204980 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 2801412 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 110058813C30371 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 110Q26434 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: P2834 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: C2630 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 4572248 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".