MEDICARE: BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1033157755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	1601 PARKVIEW AVE
Second Line	:	S300
City	:	ROCKFORD
State	:	IL
Zip	:	61107-1822
Country	:	US
Telephone Number	:	815-395-5892
Fax Number	:	815-395-5644

Provider Business Practice Location Address
First Line	:	405 CHARLES ST
Second Line	:
City	:	MT MORRIS
State	:	IL
Zip	:	61054-1646
Country	:	US
Telephone Number	:	815-734-6061
Fax Number	:	815-734-7033

Authorized Official
Title or Position	:	DIRECTOR OF PATIENT ACCOUNTS
Name	:	JOHN FITZHORN
Credential	:
Telephone Number	:	815-395-5892

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	09/10/2007

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