Healthcare Provider Details

I. General information

NPI: 1457523219
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: 04/01/2008
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 SOUTH BISHOP STREET UIH-MILE SQUARE HEALTH CENTER AT BACK OF THE YARDS
CHICAGO IL
60609-3240
US

IV. Provider business mailing address

1220 S. WOOD STREET UIH-MILE SQUARE HEALTH CENTER
CHICAGO IL
60608-1202
US

V. Phone/Fax

Practice location:
  • Phone: 773-579-9401
  • Fax: 312-413-7812
Mailing address:
  • Phone: 312-413-1261
  • Fax: 312-413-7812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. TIMOTHY STECKER
Title or Position: CFO
Credential:
Phone: 312-355-7653