Provider Demographics
NPI:1205022506
Name:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type:Organization
Organization Name:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Other - Org Name:MILE SQUARE- IHC THRESHOLDS MOTHERS PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR UIC MEDICAL PLA
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-413-0573
Mailing Address - Street 1:1110 W BELMONT AVE
Mailing Address - Street 2:IHC THRESHOLDS MOTHERS PROGRAM
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3313
Mailing Address - Country:US
Mailing Address - Phone:312-996-9354
Mailing Address - Fax:312-996-7725
Practice Address - Street 1:1110 W BELMONT AVE
Practice Address - Street 2:IHC THRESHOLDS MOTHERS PROGRAM
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3313
Practice Address - Country:US
Practice Address - Phone:312-996-9354
Practice Address - Fax:312-996-7725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14-1073OtherMEDICARE CERTIFICATION