Healthcare Provider Details

I. General information

NPI: 1679888341
Provider Name (Legal Business Name): MYSORE N SHIVARAM MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 CERMAK RD
BERWYN IL
60402-2160
US

IV. Provider business mailing address

6901 CERMAK RD
BERWYN IL
60402-2160
US

V. Phone/Fax

Practice location:
  • Phone: 708-484-5660
  • Fax: 708-484-0194
Mailing address:
  • Phone: 708-484-5660
  • Fax: 708-484-0194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number036044121
License Number StateIL

VIII. Authorized Official

Name: DR. MYSORE N SHIVARAM
Title or Position: PHYSICIAN
Credential: MD
Phone: 708-484-5660