Provider Demographics
NPI:1841614609
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:INTEGRATED HEALTH CARE - AVIVA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:RALEIGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-996-7663
Mailing Address - Street 1:845 S DAMEN AVE
Mailing Address - Street 2:M/C 802
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3727
Mailing Address - Country:US
Mailing Address - Phone:312-996-7663
Mailing Address - Fax:312-996-3512
Practice Address - Street 1:3240 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-2405
Practice Address - Country:US
Practice Address - Phone:312-413-7425
Practice Address - Fax:312-996-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1622185OtherBCBS
IL781821Medicare Oscar/Certification