Provider Demographics
NPI:1124078332
Name:BHUPALAM, SHYAM SUNDAR (MBBS)
Entity type:Individual
Prefix:DR
First Name:SHYAM SUNDAR
Middle Name:
Last Name:BHUPALAM
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053592207RN0300X
WI1717-320207RN0300X
MN70714207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003472OtherMCLAREN HEALTH PLAN-MEDICAID
MI383267121005OtherTRICARE
MI200000001254OtherPHP
MI380328OtherPHCS
MI4676459OtherAETNA
MI1003472OtherMCLAREN HEALTH ADVANTAGE
MI1003472OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI3421122Medicaid
MI4933902Medicaid
MI1003472OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI1003472OtherMCLAREN HEALTH ADVANTAGE
MI110159812OtherRAILROAD MEDICARE
MI1003472OtherMCLAREN HEALTH PLAN-MEDICAID
MI3421131Medicaid
MI4676459OtherAETNA
MI380328OtherPHCS
MIM54770004Medicare PIN