Provider Demographics
NPI:1568894715
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 CLINIC AT SOUTH BELOIT SCHOOL DISTRICT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCIAL AFFAIRS
Authorized Official - Prefix:MRS
Authorized Official - First Name:UMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-395-5637
Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5637
Mailing Address - Fax:815-395-5887
Practice Address - Street 1:245 PRAIRIE HILL RD
Practice Address - Street 2:
Practice Address - City:SOUTH BELOIT
Practice Address - State:IL
Practice Address - Zip Code:61080-2579
Practice Address - Country:US
Practice Address - Phone:815-389-9252
Practice Address - Fax:815-389-9264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid