Basic Information
| Provider Information | |||||||||
| NPI: | 1770744799 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSF MULTISPECIALTY GROUP PEORIA LLC | ||||||||
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| OtherOrganizationName: | CHILDREN'S HOSPITAL OF ILLINOIS MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 NE GLEN OAK AVE | ||||||||
| Address2: | STE 304 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033105 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 NE GLEN OAK AVE | ||||||||
| Address2: | STE 304 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096553453 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 11/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCGREW | ||||||||
| AuthorizedOfficialFirstName: | SISTER DIANE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3096552850 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSF HEALTHCARE SYSTEM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
No ID Information.