Basic Information
| Provider Information | |||||||||
| NPI: | 1174771604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANESH | ||||||||
| FirstName: | THIYAGARAJAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | STE B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602662020 | ||||||||
| FaxNumber: | 2602662009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01065538A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208M00000X | 01065538A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 83287 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 01065538A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000588059 | 01 | IN | ANTHEM | OTHER | P00664354 | 01 | IN | MEDICARE RAILROAD | OTHER | 200197150 | 05 | IN | MEDICAID |