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General NPI Number Information
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NPI Number | 1588815401
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Entity Type | Organization
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Legal Business Name | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
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Dates
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Enumeration Date | 10/09/2008
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Last Update Date | 03/19/2021
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Provider Practice Location Address
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Address Line | 3656 N HALSTED ST
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City | CHICAGO
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State | IL
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Zip | 60613-5974
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Country | US
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Telephone | 734-726-4697
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Fax | 312-413-2588
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Provider Business Mailing Address
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Address Line | 845 S DAMEN AVE M/C 802 ROOM 920
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City | CHICAGO
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State | IL
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Zip | 60612-3727
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Country | US
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Telephone | 312-413-9854
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Fax |
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Authorized Official
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Title or Position | COMPTROLLER
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Name | WALTER K. KNORR
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Credential |
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Telephone | 312-996-8800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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