Healthcare Provider Details

I. General information

NPI: 1932450160
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: 09/27/2012
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 W 39TH PL
CHICAGO IL
60632-2402
US

IV. Provider business mailing address

2045 W WASHINGTON BLVD
CHICAGO IL
60612-2428
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-1261
  • Fax: 312-413-7812
Mailing address:
  • Phone: 312-413-1261
  • 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 StateIL

VIII. Authorized Official

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