Healthcare Provider Details

I. General information

NPI: 1174771604
Provider Name (Legal Business Name): THIYAGARAJAN GANESH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

3702 NEW VISION DR STE B
FORT WAYNE IN
46845-1703
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-2020
  • Fax: 260-266-2009
Mailing address:
  • Phone: 260-266-8210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01065538A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01065538A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number83287
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01065538A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: