Provider Demographics
NPI:1396823662
Name:MARIA G IKOSSI MD PHD FACS
Entity Type:Organization
Organization Name:MARIA G IKOSSI MD PHD FACS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:IKOSSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD FACS
Authorized Official - Phone:207-782-5424
Mailing Address - Street 1:10 HIGH ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240
Mailing Address - Country:US
Mailing Address - Phone:207-782-5424
Mailing Address - Fax:207-782-1136
Practice Address - Street 1:10 HIGH ST
Practice Address - Street 2:SUITE 303
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-782-5424
Practice Address - Fax:207-782-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012822208600000X
CAC52151208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A58468Medicare UPIN
MM5210Medicare ID - Type Unspecified