Healthcare Provider Details

I. General information

NPI: 1891170924
Provider Name (Legal Business Name): MEMOONA MIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1285
  • Fax: 217-366-6129
Mailing address:
  • Phone: 217-366-1285
  • Fax: 217-366-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036162474
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: