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General NPI Number Information
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NPI Number | 1134352842
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Entity Type | Organization
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Legal Business Name | ILLINOIS SPECIALTY PHYSICIAN SERVICES AT OSF, LLC
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 08/28/2009
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Provider Practice Location Address
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Address Line | 1001 MAIN ST STE 200
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City | PEORIA
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State | IL
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Zip | 61606-1907
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Country | US
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Telephone | 309-672-5682
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Fax |
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Provider Business Mailing Address
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Address Line | 800 NE GLEN OAK AVE
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City | PEORIA
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State | IL
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Zip | 61603-3255
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Country | US
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Telephone | 309-655-2880
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JAMES M MOORE
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Credential |
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Telephone | 309-655-2880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number |
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License Number State |
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