Healthcare Provider Details

I. General information

NPI: 1619018264
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST ROOM 1411 MC 884
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

840 S WOOD ST ROOM 345H MC 884
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-6985
  • Fax: 312-355-1916
Mailing address:
  • Phone: 312-355-2035
  • Fax: 312-355-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number054.017120
License Number StateIL

VIII. Authorized Official

Name: MS. KRISTINE D VANKUIKEN
Title or Position: PHARMACY TECHNICIAN SPECIALIST
Credential:
Phone: 312-355-2035