Provider Demographics
NPI:1134352842
Name:ILLINOIS SPECIALTY PHYSICIAN SERVICES AT OSF, LLC
Entity type:Organization
Organization Name:ILLINOIS SPECIALTY PHYSICIAN SERVICES AT OSF, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-655-2880
Mailing Address - Street 1:800 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3255
Mailing Address - Country:US
Mailing Address - Phone:309-655-2880
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:STE 200
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1907
Practice Address - Country:US
Practice Address - Phone:309-672-5682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSF HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-27
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicare PIN