Provider Demographics
NPI:1639306228
Name:UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSOR/ HEAD DEPT OF PEDIATRICS
Authorized Official - Prefix:DR
Authorized Official - First Name:USHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-413-1429
Mailing Address - Street 1:1105 BRIGHTON DR
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-4327
Mailing Address - Country:US
Mailing Address - Phone:630-483-1789
Mailing Address - Fax:
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-413-1429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007222261QM1300X, 273100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No273100000XHospital UnitsEpilepsy Unit