Provider Demographics
NPI:1962490698
Name:THIYAGARAJAH, AATHIRAYEN (MD)
Entity Type:Individual
Prefix:DR
First Name:AATHIRAYEN
Middle Name:
Last Name:THIYAGARAJAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:AATHI
Other - Middle Name:
Other - Last Name:THIYAGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:325 BROAD ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4167
Mailing Address - Country:US
Mailing Address - Phone:864-373-7246
Mailing Address - Fax:864-286-3077
Practice Address - Street 1:2076 WOODRUFF RD
Practice Address - Street 2:SPINE AND PAIN CARE
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5939
Practice Address - Country:US
Practice Address - Phone:864-373-7246
Practice Address - Fax:864-286-3077
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23453174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC234534Medicaid
H680866089Medicare ID - Type Unspecified
SC234534Medicaid