MEDICARE: SHRIVETA BALRAM

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	183500000X	Pharmacist	051.307171	IL

General Provider Information

NPI Number	:	1710824164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHRIVETA BALRAM

Provider Business Mailing Address
First Line	:	5140 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1612
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5140 W DIVERSEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1612
Country	:	US
Telephone Number	:	773-685-8759
Fax Number	:

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

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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Directions to “ SHRIVETA BALRAM ” Practice Location

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