Healthcare Provider Details

I. General information

NPI: 1265977698
Provider Name (Legal Business Name): OSH-IL PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 STATE ST
EAST SAINT LOUIS IL
62205-2321
US

IV. Provider business mailing address

PO BOX 746096
ATLANTA GA
30374-6096
US

V. Phone/Fax

Practice location:
  • Phone: 618-318-8809
  • Fax: 618-615-4205
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. TERRENCE MORTON
Title or Position: CMO
Credential: MD
Phone: 704-607-4835