NPIMap

Organization Active NPI

Marymina Respiratory Medicine, LLC

  • Pulmonary Disease Physician
  • Washington, IL
National Provider Identifier
1083851174
Registry record updated Jul 10, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pulmonary Disease PhysicianTaxonomy code 207RP1001X
License
025MA069176 Issued in NJ
Legal business name
MARYMINA RESPIRATORY MEDICINE, LLC
Practice address
1740 Sycamore
Washington, IL 61571-9799
Phone
(309) 360-4879
NPI assigned
Jan 12, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 10, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ossama Ikladios, M.D.
Title
President
Phone
(309) 360-4879

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pulmonary Disease PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RP1001X 025MA069176 NJ Primary

Addresses

Primary practice location

1740 Sycamore
Washington, IL 61571-9799

Mailing address

1740 Sycamore
Washington, IL 61571-9799
Phone (309) 360-4879

Other identifiers 1

IdentifierTypeStateIssuer
8065403MedicaidNJ

National Provider Directory

National Provider Directory

Locations

370 Golf Pl
Hackensack, NJ 07601
Phone (201) 996-0573

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1231718400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1310256000000",
    "number": "1083851174",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1740 SYCAMORE",
            "city": "WASHINGTON",
            "state": "IL",
            "postal_code": "615719799",
            "telephone_number": "309-360-4879"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1740 SYCAMORE",
            "city": "WASHINGTON",
            "state": "IL",
            "postal_code": "615719799",
            "telephone_number": "309-360-4879"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARYMINA RESPIRATORY MEDICINE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-12",
        "last_updated": "2011-07-10",
        "status": "A",
        "authorized_official_last_name": "IKLADIOS",
        "authorized_official_first_name": "OSSAMA",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "309-360-4879",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207RP1001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": "NJ",
            "license": "025MA069176",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8065403",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Washington, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.