=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083851174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYMINA RESPIRATORY MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2009
-----------------------------------------------------
Last Update Date | 07/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 SYCAMORE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61571-9799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-360-4879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 SYCAMORE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61571-9799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-360-4879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. OSSAMA IKLADIOS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 309-360-4879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 025MA069176
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------