Healthcare Provider Details

I. General information

NPI: 1205022506
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: 09/20/2007
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W BELMONT AVE IHC THRESHOLDS MOTHERS PROGRAM
CHICAGO IL
60657-3313
US

IV. Provider business mailing address

1110 W BELMONT AVE IHC THRESHOLDS MOTHERS PROGRAM
CHICAGO IL
60657-3313
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-9354
  • Fax: 312-996-7725
Mailing address:
  • Phone: 312-996-9354
  • Fax: 312-996-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM R NICOLAS
Title or Position: EXECUTIVE DIRECTOR UIC MEDICAL PLA
Credential: PHD
Phone: 312-413-0573