1912711169 NPI number — OAK STREET HEALTH PHYSICIAN GROUP OF DELAWARE LLC

Table of content: (NPI 1912711169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912711169 NPI number — OAK STREET HEALTH PHYSICIAN GROUP OF DELAWARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK STREET HEALTH PHYSICIAN GROUP OF DELAWARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912711169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746763
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-352-1515
Provider Business Mailing Address Fax Number:
312-929-0373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 W 4TH ST STE 501
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19801-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-295-4730
Provider Business Practice Location Address Fax Number:
302-487-1689
Provider Enumeration Date:
02/06/2025

Additional Information

Authorized Official

Authorized Official Last Name:
MORTON
Authorized Official First Name:
TERRENCE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CMO, OWNER
Authorized Official Telephone Number:
704-607-4835

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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