Provider Demographics
NPI:1033157755
Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Other - Org Name:UNIVERSITY PRIMARY CARE CLINIC AT MT MORRIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-395-5892
Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:S300
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5892
Mailing Address - Fax:815-395-5644
Practice Address - Street 1:405 CHARLES ST
Practice Address - Street 2:
Practice Address - City:MT MORRIS
Practice Address - State:IL
Practice Address - Zip Code:61054-1646
Practice Address - Country:US
Practice Address - Phone:815-734-6061
Practice Address - Fax:815-734-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL375795Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER