MEDICARE: SATHYENDRA R MYSORE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	36943	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61-1427889	OTHER	KY	CHA
2	61-1427889	OTHER	KY	TRICARE
3	61-1427889	OTHER	KY	BLUEGRASS FAMILY HEALTH
4	61-1427889	OTHER	KY	UHC
5	61-1427889	OTHER	KY	HUMANA
6	030670000	OTHER	KY	BLACK LUNG
7	50005320	OTHER	KY	PASSPORT HEALTH PLAN
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	000000378002	OTHER	KY	ANTHEM PROVIDER #
10	C20852	OTHER	KY	CUMBERLAND HEALTHCARE INC

General Provider Information

NPI Number	:	1962476200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SATHYENDRA R MYSORE M.D.

Provider Business Mailing Address
First Line	:	740 E LAUREL RD
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-8601
Country	:	US
Telephone Number	:	606-877-3931
Fax Number	:	606-877-3978

Provider Business Practice Location Address
First Line	:	1001 SAINT JOSEPH LN
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-8345
Country	:	US
Telephone Number	:	606-330-6000
Fax Number	:	606-330-7825

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	01/22/2013

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