Provider Demographics
NPI:1144093006
Name:THE BOARD OF TRUSTEES OF UNIVERSITY OF ILLINOIS
Entity type:Organization
Organization Name:THE BOARD OF TRUSTEES OF UNIVERSITY OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM ASSOCIATE DEAN
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-413-8850
Mailing Address - Street 1:845 S DAMEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3727
Mailing Address - Country:US
Mailing Address - Phone:312-413-8850
Mailing Address - Fax:
Practice Address - Street 1:751 S SACRAMENTO BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3365
Practice Address - Country:US
Practice Address - Phone:312-413-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE BOARD OF TRUSTEE FOR THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty