Provider Demographics
NPI:1770744799
Name:OSF MULTISPECIALTY GROUP PEORIA LLC
Entity type:Organization
Organization Name:OSF MULTISPECIALTY GROUP PEORIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SISTER DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCGREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-655-2850
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:STE 304
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:STE 304
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-655-3453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSF HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-23
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
216946Medicare PIN