Healthcare Provider Details

I. General information

NPI: 1730392093
Provider Name (Legal Business Name): VIJAY THILLAINATHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JIM MASON CT
WARNER ROBINS GA
31088-8965
US

IV. Provider business mailing address

100 JIM MASON CT
WARNER ROBINS GA
31088-8965
US

V. Phone/Fax

Practice location:
  • Phone: 478-971-4001
  • Fax: 478-971-4004
Mailing address:
  • Phone: 478-971-4001
  • Fax: 478-971-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number067446
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberAS385293924
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: