Healthcare Provider Details

I. General information

NPI: 1700332392
Provider Name (Legal Business Name): NORTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W LINCOLN HWY
DEKALB IL
60115-3989
US

IV. Provider business mailing address

1525 W LINCOLN HWY STE 170
DEKALB IL
60115-3989
US

V. Phone/Fax

Practice location:
  • Phone: 815-753-0211
  • Fax:
Mailing address:
  • Phone: 815-753-0211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036.08668
License Number StateIL

VIII. Authorized Official

Name: PHIL VOORHIS
Title or Position: ASSOCIATE ATHLETIC DIRECTOR
Credential: LAT MSED.
Phone: 815-753-0211