Provider Demographics
NPI:1639355050
Name:MYSORE SHIVARAM, MD, SC
Entity Type:Organization
Organization Name:MYSORE SHIVARAM, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MYSORE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHIVARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-425-8232
Mailing Address - Street 1:7400 W RAWSON AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8278
Mailing Address - Country:US
Mailing Address - Phone:414-425-8232
Mailing Address - Fax:
Practice Address - Street 1:7400 W RAWSON AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8278
Practice Address - Country:US
Practice Address - Phone:414-425-8232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB85250Medicare UPIN