MEDICARE: THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	363LF0000X	Family Nurse Practitioner
3	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1588815401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	845 S DAMEN AVE
Second Line	:	M/C 802 ROOM 920
City	:	CHICAGO
State	:	IL
Zip	:	60612-3727
Country	:	US
Telephone Number	:	312-413-9854
Fax Number	:

Provider Business Practice Location Address
First Line	:	3656 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5974
Country	:	US
Telephone Number	:	734-726-4697
Fax Number	:	312-413-2588

Authorized Official
Title or Position	:	COMPTROLLER
Name	:	WALTER K. KNORR
Credential	:
Telephone Number	:	312-996-8800

Provider Enumeration Date	:	10/09/2008
Last Update Date	:	03/19/2021

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