Provider Demographics
NPI:1205873437
Name:FATIANOV, TAMARA I (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:I
Last Name:FATIANOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 140
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4566
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6195
Practice Address - Street 1:877 W FARIS RD
Practice Address - Street 2:SUITE D
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4254
Practice Address - Country:US
Practice Address - Phone:864-455-8001
Practice Address - Fax:864-455-8800
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-04-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC23132208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863063OtherBCBS OF SC
SCP00163870OtherRR MEDICARE
SCP00801300OtherRR MEDICARE
SC7375503OtherAETNA
SC4581701OtherCIGNA
SC231323Medicaid
SC4581701OtherCIGNA
SCP00801300OtherRR MEDICARE
SCH620447951Medicare PIN