# MYSORE N SHIVARAM MD SC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679888341
- **Authorized official:** DR. MYSORE N SHIVARAM MD (PHYSICIAN)
- **Authorized official phone:** (708) 484-5660

## Contact information

- **Practice address:** 6901 CERMAK RD, BERWYN, IL 60402-2160
- **Practice address phone:** (708) 484-5660
- **Practice address fax:** (708) 484-0194
- **Mailing address:** 6901 CERMAK RD, BERWYN, IL 60402-2160
- **Mailing address phone:** (708) 484-5660
- **Mailing address fax:** (708) 484-0194

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RA0401X | Addiction Medicine (Internal Medicine) Physician | 036044121 | IL | Yes |

## Other

- **Enumeration date:** 08/18/2010
- **Last updated:** 10/15/2014