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)		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1622185	OTHER	IL	BLUE CROSS

General Provider Information

NPI Number	:	1932450160
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	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-2428
Country	:	US
Telephone Number	:	312-413-1261
Fax Number	:	312-413-7812

Provider Business Practice Location Address
First Line	:	3050 W 39TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2402
Country	:	US
Telephone Number	:	312-413-1261
Fax Number	:	312-413-7812

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. HENRY TAYLOR
Credential	:	CEO
Telephone Number	:	312-312-1261

Provider Enumeration Date	:	09/27/2012
Last Update Date	:	10/15/2020

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

Language	Start Address	Practice Location

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