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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1245335892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	6114 PAYSPHERE CIR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60674-0061
Country	:	US
Telephone Number	:	312-996-7708
Fax Number	:

Provider Business Practice Location Address
First Line	:	2242 W HARRISON ST
Second Line	:	SUITE 104
City	:	CHICAGO
State	:	IL
Zip	:	60612-3515
Country	:	US
Telephone Number	:	312-996-7708
Fax Number	:	312-413-0503

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MR. WALTER K KNORR
Credential	:
Telephone Number	:	312-996-2862

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	04/20/2010

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