Provider Demographics
NPI:1194817619
Name:SHIVARAM, INDU (MD)
Entity Type:Individual
Prefix:
First Name:INDU
Middle Name:
Last Name:SHIVARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 FLEMINGSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1015
Mailing Address - Country:US
Mailing Address - Phone:606-780-5500
Mailing Address - Fax:
Practice Address - Street 1:245 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1015
Practice Address - Country:US
Practice Address - Phone:606-780-5500
Practice Address - Fax:606-780-5512
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176776207R00000X, 207RC0200X, 207RP1001X
VA0101265411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100905520Medicaid
KY57647OtherMED LICENSE
NY01260360Medicaid