Healthcare Provider Details

I. General information

NPI: 1326483991
Provider Name (Legal Business Name): BOARD OF TRUSTEES FO THE UNIVERSITY OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S PAULINA ST # MC588
CHICAGO IL
60612-4353
US

IV. Provider business mailing address

7732 SOLUTION CENTER
CHICAGO IL
60677-0001
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7546
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MR. MARC WILLIAM DEVAR
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 312-376-1607