Healthcare Provider Details

I. General information

NPI: 1124212956
Provider Name (Legal Business Name): VISHNAMPET SVERAMANIAM THYAGARAJAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEALTH CLINIC EGLER FACILITY STATE PRISON
JACKSON MI
49201
US

IV. Provider business mailing address

3360 WESTLANE
JACKSON MI
49203
US

V. Phone/Fax

Practice location:
  • Phone: 517-780-5991
  • Fax:
Mailing address:
  • Phone: 517-782-2082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301031692
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: