Organization
MYSORE N SHIVARAM MD SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MYSORE N SHIVARAM MD (PHYSICIAN)
(708) 484-5660
Entity
Organization
Contact information
Practice address
6901 CERMAK RD, BERWYN, IL 60402-2160
(708) 484-5660
(708) 484-0194
Mailing address
6901 CERMAK RD, BERWYN, IL 60402-2160
(708) 484-5660
(708) 484-0194
Taxonomy
Speciality
Code
Description
License number
State
207RA0401X
Addiction Medicine (Internal Medicine) Physician
Primary
036044121
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036044121
—
IL
Enumeration date
08/18/2010
Last updated
10/15/2014
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