Healthcare Provider Details

I. General information

NPI: 1639355050
Provider Name (Legal Business Name): MYSORE SHIVARAM, MD, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 W RAWSON AVE SUITE 225
FRANKLIN WI
53132-8278
US

IV. Provider business mailing address

7400 W RAWSON AVE SUITE 225
FRANKLIN WI
53132-8278
US

V. Phone/Fax

Practice location:
  • Phone: 414-425-8232
  • Fax:
Mailing address:
  • Phone: 414-425-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number22232
License Number StateWI

VIII. Authorized Official

Name: DR. MYSORE S SHIVARAM
Title or Position: PROPRIETOR
Credential: M.D.
Phone: 414-425-8232