Provider Demographics
NPI:1609822147
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:DEPARTMENT OF PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHYSICIAN PRACTICE
Authorized Official - Prefix:MS
Authorized Official - First Name:SUNITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRABHAKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CPC
Authorized Official - Phone:312-413-3783
Mailing Address - Street 1:7825 SOLUTION CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-7008
Mailing Address - Country:US
Mailing Address - Phone:312-996-7383
Mailing Address - Fax:312-996-3514
Practice Address - Street 1:912 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4300
Practice Address - Country:US
Practice Address - Phone:312-413-3783
Practice Address - Fax:312-996-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203465OtherMEDICARE APN/CNS
IL01618662OtherBLUE CROSS BLUE SHIELD
IL203465OtherMEDICARE APN/CNS
IL939920Medicare ID - Type UnspecifiedMD GROUP NUMBER
IL939921Medicare ID - Type UnspecifiedLCSW GROUP NUMBER