Provider Demographics
NPI: | 1881821445 |
---|---|
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: | DEPT OF SURGERY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | WILLIAM |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | NICHOLAS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHD |
Authorized Official - Phone: | 312-413-1350 |
Mailing Address - Street 1: | 135 S LASALLE ST DEPT 3449 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60674-0001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 840 S WOOD ST |
Practice Address - Street 2: | MC 958 |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60612-4325 |
Practice Address - Country: | US |
Practice Address - Phone: | 312-996-9336 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | DEPT OF SURGERY-CHS-WEISS |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2009-06-22 |
Last Update Date: | 2009-06-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
204E00000X, 204F00000X, 208200000X, 2082S0099X, 2082S0105X, 208600000X, 2086S0102X, 2086S0105X, 2086S0120X, 2086S0122X, 2086S0127X, 2086S0129X, 208C00000X, 208G00000X | ||
IL | 2086S0129X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | Group - Multi-Specialty | |
No | 204F00000X | Allopathic & Osteopathic Physicians | Transplant Surgery | Group - Multi-Specialty | |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2082S0099X | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | Group - Multi-Specialty |
No | 2082S0105X | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | Group - Multi-Specialty |
No | 2086S0102X | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | Group - Multi-Specialty |
No | 2086S0105X | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | Group - Multi-Specialty |
No | 2086S0120X | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | Group - Multi-Specialty |
No | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | Group - Multi-Specialty |
No | 2086S0127X | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | Group - Multi-Specialty |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
No | 208C00000X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 004 | Other | TRICARE GROUP |
IL | CA8300 | Other | RAILROAD GROUP |
IL | 932760 | Other | MEDICARE GROUP |
IL | 01618613 | Other | BCBS GROUP |