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	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1952713323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	8131 S MAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3007
Country	:	US
Telephone Number	:	312-996-4656
Fax Number	:	312-996-3848

Provider Business Practice Location Address
First Line	:	8131 S MAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3007
Country	:	US
Telephone Number	:	312-996-4656
Fax Number	:	312-996-3848

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. CYNTHIA BOYD
Credential	:	PHD, FAAN
Telephone Number	:	312-996-4656

Provider Enumeration Date	:	05/20/2014
Last Update Date	:	05/28/2014

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