Provider Demographics
NPI:1588815401
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 NURSING FACULTY PRACTICE AND PARTNERSHIPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:K
Authorized Official - Last Name:KNORR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-996-8800
Mailing Address - Street 1:845 S DAMEN AVE
Mailing Address - Street 2:M/C 802 ROOM 920
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3727
Mailing Address - Country:US
Mailing Address - Phone:312-413-9854
Mailing Address - Fax:
Practice Address - Street 1:3656 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-5974
Practice Address - Country:US
Practice Address - Phone:734-726-4697
Practice Address - Fax:312-413-2588
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-09
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL544480Medicare Oscar/Certification