Healthcare Provider Details

I. General information

NPI: 1972079358
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: 10/23/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 W DIVISION ST
CHICAGO IL
60651-2405
US

IV. Provider business mailing address

1220 S WOOD ST
CHICAGO IL
60608-1202
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-7425
  • Fax:
Mailing address:
  • Phone: 312-413-1261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY TAYLOR
Title or Position: CEO
Credential:
Phone: 312-413-1261