Healthcare Provider Details

I. General information

NPI: 1316537889
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 S WOOD ST
CHICAGO IL
60612-4300
US

IV. Provider business mailing address

7732 SOLUTIONS CENTER
CHICAGO IL
60677-7007
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-1000
  • Fax:
Mailing address:
  • Phone: 312-355-6468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KAILAS SANGHANI
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 312-355-6468