Provider Demographics
NPI:1407802960
Name:SIVAM, GEETHA (MD)
Entity Type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:SIVAM
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 1:9725 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-3616
Mailing Address - Country:US
Mailing Address - Phone:219-924-5300
Mailing Address - Fax:219-924-7041
Practice Address - Street 1:9725 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-3616
Practice Address - Country:US
Practice Address - Phone:219-924-5300
Practice Address - Fax:219-924-7041
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037848208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100349810Medicaid
INE92067Medicare UPIN