Healthcare Provider Details

I. General information

NPI: 1275688160
Provider Name (Legal Business Name): NORTHERN ILLINOIS UNIVERSITY HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 LUCINDA AVE HEALTH SERVICES BUILDING
DEKALB IL
60115
US

IV. Provider business mailing address

518 LUCINDA AVE. HEALTH SERVICES BUILDING
DEKALB IL
60115-2854
US

V. Phone/Fax

Practice location:
  • Phone: 815-753-1311
  • Fax: 815-753-9570
Mailing address:
  • Phone: 815-753-1311
  • Fax: 815-753-9570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINE J. GRADY
Title or Position: DIRECTOR, HEALTH SERVICES
Credential: R.N., M.S.
Phone: 815-753-1311