Provider Demographics
NPI:1407307812
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:UIC HEALTHSPAN FACULTY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEAN, APPLIED HEALTH SCIENCES
Authorized Official - Prefix:DR
Authorized Official - First Name:BO
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNHALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-996-6695
Mailing Address - Street 1:5254 SOLUTION CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0001
Mailing Address - Country:US
Mailing Address - Phone:312-996-4404
Mailing Address - Fax:
Practice Address - Street 1:1640 W ROOSEVELT RD
Practice Address - Street 2:ROOM 336
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1316
Practice Address - Country:US
Practice Address - Phone:312-413-8043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty