Provider Demographics
NPI:1679888341
Name:MYSORE N SHIVARAM MD SC
Entity Type:Organization
Organization Name:MYSORE N SHIVARAM MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MYSORE
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHIVARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-484-5660
Mailing Address - Street 1:6901 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2160
Mailing Address - Country:US
Mailing Address - Phone:708-484-5660
Mailing Address - Fax:708-484-0194
Practice Address - Street 1:6901 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2160
Practice Address - Country:US
Practice Address - Phone:708-484-5660
Practice Address - Fax:708-484-0194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-18
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044121207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044121Medicaid
IL468630Medicare PIN
ILD12503Medicare UPIN