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 State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)
2	204F00000X	Transplant Surgery Physician
3	208200000X	Plastic Surgery Physician
4	2082S0099X	Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician
5	2082S0105X	Surgery of the Hand (Plastic Surgery) Physician
6	2086S0102X	Surgical Critical Care Physician
7	2086S0105X	Surgery of the Hand (Surgery) Physician
8	2086S0120X	Pediatric Surgery Physician
9	2086S0122X	Plastic and Reconstructive Surgery Physician
10	2086S0127X	Trauma Surgery Physician
11	2086S0129X	Vascular Surgery Physician
12	2086S0129X	Vascular Surgery Physician	IL
13	208C00000X	Colon & Rectal Surgery Physician
14	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
15	208600000X	Surgery Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	932760	OTHER	IL	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	004	OTHER	IL	TRICARE GROUP
2	CA8300	OTHER	IL	RAILROAD GROUP
4	01618613	OTHER	IL	BCBS GROUP

General Provider Information

NPI Number	:	1881821445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	135 S LASALLE ST DEPT 3449
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60674-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	840 S WOOD ST
Second Line	:	MC 958
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-996-9336
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. WILLIAM R. NICHOLAS
Credential	:	PHD
Telephone Number	:	312-413-1350

Provider Enumeration Date	:	06/22/2009
Last Update Date	:	06/22/2009

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

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