MEDICARE: 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	3336C0002X	Clinic Pharmacy	054.017120	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	054-017120	OTHER	IL	SATE LICENSE NUMBER
2	032-006005	OTHER	IL	STATE CONTROLLED SUBSTANC
3	1453416	OTHER	IL	NCPDP NUMBER

General Provider Information

NPI Number	:	1619018264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	840 S WOOD ST
Second Line	:	ROOM 345H MC 884
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-355-2035
Fax Number	:	312-355-1916

Provider Business Practice Location Address
First Line	:	1801 W TAYLOR ST
Second Line	:	ROOM 1411 MC 884
City	:	CHICAGO
State	:	IL
Zip	:	60612-4795
Country	:	US
Telephone Number	:	312-996-6985
Fax Number	:	312-355-1916

Authorized Official
Title or Position	:	PHARMACY TECHNICIAN SPECIALIST
Name	:	MS. KRISTINE D VANKUIKEN
Credential	:
Telephone Number	:	312-355-2035

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	03/07/2023

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

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