Provider Demographics
NPI:1538160742
Name:THAVARAJAH, KRISHNAPILLAI (MD)
Entity type:Individual
Prefix:
First Name:KRISHNAPILLAI
Middle Name:
Last Name:THAVARAJAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77000 DEPT 771255
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2000
Mailing Address - Country:US
Mailing Address - Phone:313-271-3000
Mailing Address - Fax:313-271-3003
Practice Address - Street 1:16407 SOUTHFIELD RD
Practice Address - Street 2:STE A
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2571
Practice Address - Country:US
Practice Address - Phone:313-271-3000
Practice Address - Fax:313-271-3003
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIA301033660207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG02484OtherBLUECARE NETWORK
MI103192OtherGREAT LAKES HEALTH PLAN
MI4098OtherCAPE HEALTH PLAN
MI108137OtherCARE CHOICES
MI204980OtherFEDERAL BLACK LUNG
MI2801412Medicaid
MI110058813C30371OtherTRAVELERS MEDICARE
MI110Q26434OtherBLUE CROSS BLUE SHIELD
MIP2834OtherBLUECARE NETWORK
MIC2630OtherM-CARE
MI4572248OtherAETNA
MIG02484OtherBLUECARE NETWORK
MI4098OtherCAPE HEALTH PLAN