Basic Information
| Provider Information | |||||||||
| NPI: | 1962476200 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYSORE | ||||||||
| FirstName: | SATHYENDRA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 E LAUREL RD | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068773931 | ||||||||
| FaxNumber: | 6068773978 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 SAINT JOSEPH LN | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063306000 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 36943 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 61-1427889 | 01 | KY | CHA | OTHER | 61-1427889 | 01 | KY | TRICARE | OTHER | 61-1427889 | 01 | KY | BLUEGRASS FAMILY HEALTH | OTHER | 61-1427889 | 01 | KY | UHC | OTHER | 61-1427889 | 01 | KY | HUMANA | OTHER | 030670000 | 01 | KY | BLACK LUNG | OTHER | 50005320 | 01 | KY | PASSPORT HEALTH PLAN | OTHER | 64060783 | 05 | KY | MEDICAID | 000000378002 | 01 | KY | ANTHEM PROVIDER # | OTHER | C20852 | 01 | KY | CUMBERLAND HEALTHCARE INC | OTHER |