Provider Demographics
NPI:1760400170
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:UIH-MILE SQUARE HEALTH CENTER AT SOUTH SHORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-413-1261
Mailing Address - Street 1:1220 S. WOOD STREET
Mailing Address - Street 2:UIH-MILE SQUARE HEALTH CENTER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1202
Mailing Address - Country:US
Mailing Address - Phone:312-413-1261
Mailing Address - Fax:312-413-7815
Practice Address - Street 1:7131 S. JEFFREY BLVD
Practice Address - Street 2:UIH-MILE SQUARE HEALTH CENTER AT SOUTH SHORE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2497
Practice Address - Country:US
Practice Address - Phone:773-256-0526
Practice Address - Fax:312-413-7812
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBCBS PROVIDEROther1622185
ILBCBS PROVIDEROther1622185