Basic Information
| Provider Information | |||||||||
| NPI: | 1235754995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OAK STREET HEALTH PHYSICIANS GROUP OF MISSISSIPPI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W MONROE ST STE 1200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606032420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 ELLIS AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015337016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2020 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | GRIFFIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 3127339730 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.