MEDICARE: THE 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	261QF0400X	Federally Qualified Health Center (FQHC)

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14-1073	OTHER	IL	MEDICARE CERTIFICATION

General Provider Information

NPI Number	:	1205022506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	1110 W BELMONT AVE
Second Line	:	IHC THRESHOLDS MOTHERS PROGRAM
City	:	CHICAGO
State	:	IL
Zip	:	60657-3313
Country	:	US
Telephone Number	:	312-996-9354
Fax Number	:	312-996-7725

Provider Business Practice Location Address
First Line	:	1110 W BELMONT AVE
Second Line	:	IHC THRESHOLDS MOTHERS PROGRAM
City	:	CHICAGO
State	:	IL
Zip	:	60657-3313
Country	:	US
Telephone Number	:	312-996-9354
Fax Number	:	312-996-7725

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR UIC MEDICAL PLA
Name	:	DR. WILLIAM R NICOLAS
Credential	:	PHD
Telephone Number	:	312-413-0573

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	08/05/2008

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Directions to “THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS ” Practice Location

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