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)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1622185	OTHER		BCBS PROVIDER ID

General Provider Information

NPI Number	:	1295751212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	2045 W WASHINGTON BLVD
Second Line	:	M/C 698
City	:	CHICAGO
State	:	IL
Zip	:	60612-2428
Country	:	US
Telephone Number	:	312-996-2000
Fax Number	:	312-413-1782

Provider Business Practice Location Address
First Line	:	2310 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1131
Country	:	US
Telephone Number	:	312-996-2000
Fax Number	:	312-413-1782

Authorized Official
Title or Position	:	ASSOCIATE DIRECTOR
Name	:	INN LEE
Credential	:
Telephone Number	:	312-413-9854

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/04/2008

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

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