Provider Demographics
NPI:1548697964
Name:SIVA, SHIVI S (MD)
Entity type:Individual
Prefix:DR
First Name:SHIVI
Middle Name:S
Last Name:SIVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHIVI
Other - Middle Name:S
Other - Last Name:SUDHAGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:600 NORTHERN BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5200
Mailing Address - Country:US
Mailing Address - Phone:516-387-3990
Mailing Address - Fax:309-277-1191
Practice Address - Street 1:600 NORTHERN BLVD STE 111
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5200
Practice Address - Country:US
Practice Address - Phone:516-387-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11017474A207RG0100X
IL036138438207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138438Medicaid
ILF400318210Medicare PIN