MEDICARE: UNIV. OF ILLINOIS AT CHICAGO

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	293D00000X	Physiological Laboratory	D0030401	MD

General Provider Information

NPI Number	:	1336399583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIV. OF ILLINOIS AT CHICAGO

Provider Business Mailing Address
First Line	:	509 AURORA AVE
Second Line	:	305
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-6221
Country	:	US
Telephone Number	:	630-527-0735
Fax Number	:

Provider Business Practice Location Address
First Line	:	851 S MORGAN ST
Second Line	:	SEO, MC 063, ROOM 218
City	:	CHICAGO
State	:	IL
Zip	:	60607-7042
Country	:	US
Telephone Number	:	312-996-2335
Fax Number	:	312-996-5921

Authorized Official
Title or Position	:	PROFESSOR OF BIOENGINEERING
Name	:	PROF. PERCIVAL DAVIS MCCORMACK
Credential	:	M.D.,PH.D.
Telephone Number	:	312-996-2335

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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