Provider Demographics
NPI:1619959137
Name:SHIVARAM, KALUGOTLA N (MD)
Entity Type:Individual
Prefix:DR
First Name:KALUGOTLA
Middle Name:N
Last Name:SHIVARAM
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 1:842 BELLERIVE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-3201
Mailing Address - Country:US
Mailing Address - Phone:636-887-4288
Mailing Address - Fax:
Practice Address - Street 1:1111 W PEARCE BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1020
Practice Address - Country:US
Practice Address - Phone:636-887-4288
Practice Address - Fax:636-639-2368
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086751207P00000X
MO111383207PP0204X, 207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207245606Medicaid
IL036086751Medicaid
MOG10371Medicare UPIN
IL036086751Medicaid
MO207245606Medicaid
MO003014740Medicare PIN
MO003015439Medicare PIN
MO003014748Medicare PIN