Healthcare Provider Details

I. General information

NPI: 1295751220
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: 07/14/2006
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 S CALUMET AVE
CHICAGO IL
60616-2901
US

IV. Provider business mailing address

1220 S WOOD ST M/C 698
CHICAGO IL
60608-1202
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2000
  • Fax: 312-413-1782
Mailing address:
  • Phone: 312-996-2000
  • Fax: 312-413-7812

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: MR. HENRY TAYLOR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 312-413-1261