Provider Demographics
NPI:1578771010
Name:BAHRAMI, SHAHRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:BAHRAMI
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:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-2591
Mailing Address - Fax:920-320-5106
Practice Address - Street 1:2300 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3712
Practice Address - Country:US
Practice Address - Phone:920-320-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086575207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine