Basic Information
| Provider Information | |||||||||
| NPI: | 1881900652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYSORE | ||||||||
| FirstName: | CHANNAIAH | ||||||||
| MiddleName: | SRIKANTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007495191 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007495191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2010 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | D77961 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.