Provider Demographics
NPI:1104401454
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:
Other - Org Type:
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVIJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-333-1202
Mailing Address - Street 1:603 EAST DANIEL STREET
Mailing Address - Street 2:ROOM 327, BRENDA REINHOLD
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820
Mailing Address - Country:US
Mailing Address - Phone:217-244-4613
Mailing Address - Fax:
Practice Address - Street 1:301 N NEIL ST STE 210
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3166
Practice Address - Country:US
Practice Address - Phone:217-244-4597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty