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General NPI Number Information
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NPI Number | 1255761961
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Entity Type | Organization
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Legal Business Name | BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
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Dates
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Enumeration Date | 11/15/2013
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Last Update Date | 04/27/2016
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Provider Practice Location Address
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Address Line | 330 15TH AVE
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City | ROCKFORD
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State | IL
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Zip | 61104-5155
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Country | US
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Telephone | 815-395-5858
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Fax | 815-968-2035
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Provider Business Mailing Address
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Address Line | 1601 PARKVIEW AVE
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City | ROCKFORD
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State | IL
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Zip | 61107-1822
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Country | US
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Telephone | 815-385-5637
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Fax | 815-395-5887
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Authorized Official
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Title or Position | DIRECTOR OF FISCAL AFFAIRS
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Name | MRS. UMA SRIRAM
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Credential |
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Telephone | 815-395-5637
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number |
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License Number State |
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