Provider Demographics
NPI:1245335892
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:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:K
Authorized Official - Last Name:KNORR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-996-2862
Mailing Address - Street 1:6114 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0061
Mailing Address - Country:US
Mailing Address - Phone:312-996-7708
Mailing Address - Fax:
Practice Address - Street 1:2242 W HARRISON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3515
Practice Address - Country:US
Practice Address - Phone:312-996-7708
Practice Address - Fax:312-413-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0582290009Medicare NSC