Healthcare Provider Details

I. General information

NPI: 1033157755
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: 06/03/2006
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 CHARLES ST
MT MORRIS IL
61054-1646
US

IV. Provider business mailing address

1601 PARKVIEW AVE S300
ROCKFORD IL
61107-1822
US

V. Phone/Fax

Practice location:
  • Phone: 815-734-6061
  • Fax: 815-734-7033
Mailing address:
  • Phone: 815-395-5892
  • Fax: 815-395-5644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN FITZHORN
Title or Position: DIRECTOR OF PATIENT ACCOUNTS
Credential:
Phone: 815-395-5892