Healthcare Provider Details

I. General information

NPI: 1407307812
Provider Name (Legal Business Name): THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 W ROOSEVELT RD ROOM 336
CHICAGO IL
60608-1316
US

IV. Provider business mailing address

5254 SOLUTION CENTER
CHICAGO IL
60677-0001
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-8043
  • Fax:
Mailing address:
  • Phone: 312-996-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BO FERNHALL
Title or Position: DEAN, APPLIED HEALTH SCIENCES
Credential: PH.D.
Phone: 312-996-6695