MEDICARE: UNIVERSITY OF ILLINOIS - CHICAGO

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QX0100X	Occupational Medicine Clinic/Center
2	101YP2500X	Professional Counselor
3	103K00000X	Behavior Analyst
4	103TC0700X	Clinical Psychologist
5	1041C0700X	Clinical Social Worker
6	222Q00000X	Developmental Therapist
7	225100000X	Physical Therapist
8	225XP0200X	Pediatric Occupational Therapist
9	235Z00000X	Speech-Language Pathologist
10	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1174554331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF ILLINOIS - CHICAGO

Provider Business Mailing Address
First Line	:	5254 SOLUTION CENTER
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-0001
Country	:	US
Telephone Number	:	312-413-1567
Fax Number	:	312-413-1993

Provider Business Practice Location Address
First Line	:	1640 W ROOSEVELT RD
Second Line	:	ROOM 336 (MC 628)
City	:	CHICAGO
State	:	IL
Zip	:	60608-1316
Country	:	US
Telephone Number	:	312-413-1567
Fax Number	:	312-413-1993

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. BO L. FERNHALL
Credential	:	PHD
Telephone Number	:	312-413-1567

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	01/20/2022

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Directions to “UNIVERSITY OF ILLINOIS - CHICAGO ” Practice Location

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