Healthcare Provider Details

I. General information

NPI: 1720513906
Provider Name (Legal Business Name): UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

1203 E BRIGHTWATER LN
BOISE ID
83706-6718
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 208-863-7795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number209007222
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code273100000X
TaxonomyEpilepsy Hospital Unit
License Number209007222
License Number StateIL

VIII. Authorized Official

Name: DR. BRIAN THOMAS HUNTINGTON
Title or Position: RESIDENT PHYSICIAN
Credential: M.D.
Phone: 208-863-7795