Healthcare Provider Details

I. General information

NPI: 1043727571
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: 01/05/2018
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S. WOLCOTT SUITE E-144; MC 684
CHICAGO IL
60612
US

IV. Provider business mailing address

7732 SOLUTIONS CENTER
CHICAGO IL
60677-7007
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7420
  • Fax: 312-413-8485
Mailing address:
  • Phone: 312-413-0369
  • Fax: 312-413-8485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL A BAKSTON
Title or Position: INTERIM DIRECTOR
Credential: MD, MPH, MBA
Phone: 312-355-3554