Healthcare Provider Details

I. General information

NPI: 1205873437
Provider Name (Legal Business Name): TAMARA I FATIANOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 W FARIS RD SUITE D
GREENVILLE SC
29605-4254
US

IV. Provider business mailing address

7 INDEPENDENCE PT SUITE 140
GREENVILLE SC
29615-4566
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-8001
  • Fax: 864-455-8800
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number23132
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: