Provider Demographics
NPI:1295751220
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:EXECUTIVE DIRECTOR
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 ST
Mailing Address - Street 2:M/C 698
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1202
Mailing Address - Country:US
Mailing Address - Phone:312-996-2000
Mailing Address - Fax:312-413-7812
Practice Address - Street 1:2641 S CALUMET AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2901
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:2006-07-14
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1622185OtherBCBS PROVIDER ID