Basic Information
| Provider Information | |||||||||
| NPI: | 1821584780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYSORE | ||||||||
| FirstName: | SUKRITA | ||||||||
| MiddleName: | SHESHU | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SHESHU | ||||||||
| OtherFirstName: | SUKRITA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 224 CHURCH ST APT 403 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191064567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047786403 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 UPPER CHESAPEAKE DR | ||||||||
| Address2: | |||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210144324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436431500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2018 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | D91596 | MD | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | D91596 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.