Provider Demographics
NPI:1245412683
Name:ANJANEYULU THAGIRISA, M.D.
Entity Type:Organization
Organization Name:ANJANEYULU THAGIRISA, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANJANEYULU
Authorized Official - Middle Name:
Authorized Official - Last Name:THAGIRISA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-367-0043
Mailing Address - Street 1:PO BOX 2990
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-2990
Mailing Address - Country:US
Mailing Address - Phone:304-367-0043
Mailing Address - Fax:
Practice Address - Street 1:1539 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1306
Practice Address - Country:US
Practice Address - Phone:304-367-0043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011274Medicaid
9300932Medicare PIN