Basic Information
| Provider Information | |||||||||
| NPI: | 1922445527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSF MULTI-SPECIALTY GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SW ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096552850 | ||||||||
| FaxNumber: | 3096554878 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 N STATE ROUTE 91 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096835050 | ||||||||
| FaxNumber: | 3096834739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | KRANTZ | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER, STRATEGIC REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 3096552865 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSF HEALTHCARE SYSTEM | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000 | 05 | IL | MEDICAID |