Provider Demographics
NPI:1285071860
Name:SIVAGURUNATHAN, AJANTHAN (MD)
Entity type:Individual
Prefix:
First Name:AJANTHAN
Middle Name:
Last Name:SIVAGURUNATHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 NORTH LAFAYETTE
Mailing Address - Street 2:PROVIDENCE MEDICAL CENTER - SOUTH LYON,
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178
Mailing Address - Country:US
Mailing Address - Phone:248-437-1744
Mailing Address - Fax:248-437-3245
Practice Address - Street 1:210 NORTH LAFAYETTE
Practice Address - Street 2:PROVIDENCE MEDICAL CENTER - SOUTH LYON,
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178
Practice Address - Country:US
Practice Address - Phone:248-437-1744
Practice Address - Fax:248-437-3245
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program