Provider Demographics
NPI:1659501500
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 MAXILLOFACIAL PROSTHETICS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:APPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-996-3620
Mailing Address - Street 1:1740 W TAYLOR ST # MC693
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7232
Mailing Address - Country:US
Mailing Address - Phone:312-996-3620
Mailing Address - Fax:312-996-0850
Practice Address - Street 1:811 S PAULINA ST
Practice Address - Street 2:118 DENT, MC 588
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4353
Practice Address - Country:US
Practice Address - Phone:312-996-6933
Practice Address - Fax:312-355-4173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-24
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0582290011Medicare NSC