Healthcare Provider Details

I. General information

NPI: 1750318903
Provider Name (Legal Business Name): MYSORE S SHIVARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

7400 W RAWSON AVE STE 243
FRANKLIN WI
53132-8280
US

V. Phone/Fax

Practice location:
  • Phone: 414-425-8232
  • Fax: 414-425-8267
Mailing address:
  • Phone: 414-425-8232
  • Fax: 414-425-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number22232
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: