Healthcare Provider Details

I. General information

NPI: 1780309948
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: 10/10/2022
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 S PULASKI RD STE 150
CHICAGO IL
60629-4400
US

IV. Provider business mailing address

7702 SOLUTION CENTER
CHICAGO IL
60677-7007
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-5570
  • Fax:
Mailing address:
  • Phone: 312-413-3282
  • Fax:

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: HENRY TAYLOR
Title or Position: CEO
Credential:
Phone: 312-413-3282