Provider Demographics
NPI:1790704484
Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Other - Org Name:SMYTH JOYNER SCHOOL BASED CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:INN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-413-9854
Mailing Address - Street 1:2045 W WASHINGTON BLVD
Mailing Address - Street 2:M/C 698
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2428
Mailing Address - Country:US
Mailing Address - Phone:312-996-2000
Mailing Address - Fax:312-413-1782
Practice Address - Street 1:1059 W 13TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1526
Practice Address - Country:US
Practice Address - Phone:312-996-2000
Practice Address - Fax:312-413-1782
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-19
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1622185OtherBCBS PROVIDER ID