Healthcare Provider Details

I. General information

NPI: 1881682904
Provider Name (Legal Business Name): SHYAM S IVATURI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 280
SAINT LOUIS MO
63128-3287
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE 280
SAINT LOUIS MO
63128-3287
US

V. Phone/Fax

Practice location:
  • Phone: 314-892-6565
  • Fax: 314-892-4828
Mailing address:
  • Phone: 314-892-6565
  • Fax: 314-892-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2001006095
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2001006095
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: