Basic Information
| Provider Information | |||||||||
| NPI: | 1811405533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSH - PA PHYSICIANS GROUP, PC | ||||||||
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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: | 5050 PARKSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191314714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2018 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | GRIFFIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 3127339730 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | MD458986 | 01 | PA | MEDICAL LICENSE | OTHER |