=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043727571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2018
-----------------------------------------------------
Last Update Date | 07/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 835 S. WOLCOTT SUITE E-144; MC 684
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-996-7420
-----------------------------------------------------
Fax | 312-413-8485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7732 SOLUTIONS CENTER
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-7007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-413-0369
-----------------------------------------------------
Fax | 312-413-8485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERIM DIRECTOR
-----------------------------------------------------
Name | DANIEL A BAKSTON
-----------------------------------------------------
Credential | MD, MPH, MBA
-----------------------------------------------------
Telephone | 312-355-3554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------