Provider Demographics
NPI:1750318903
Name:SHIVARAM, MYSORE S (MD)
Entity Type:Individual
Prefix:
First Name:MYSORE
Middle Name:S
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 1:7400 W RAWSON AVE
Mailing Address - Street 2:STE 243
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8280
Mailing Address - Country:US
Mailing Address - Phone:414-425-8232
Mailing Address - Fax:414-425-8267
Practice Address - Street 1:7400 W RAWSON AVE
Practice Address - Street 2:#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:414-425-8267
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22232207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30256600Medicaid
WI001401621Medicare PIN
WIB85250Medicare UPIN
WI01199Medicare PIN