Provider Demographics
NPI:1336399583
Name:UNIV. OF ILLINOIS AT CHICAGO
Entity Type:Organization
Organization Name:UNIV. OF ILLINOIS AT CHICAGO
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:PROFESSOR OF BIOENGINEERING
Authorized Official - Prefix:PROF
Authorized Official - First Name:PERCIVAL
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:312-996-2335
Mailing Address - Street 1:509 AURORA AVE
Mailing Address - Street 2:305
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6221
Mailing Address - Country:US
Mailing Address - Phone:630-527-0735
Mailing Address - Fax:
Practice Address - Street 1:851 S MORGAN ST
Practice Address - Street 2:SEO, MC 063, ROOM 218
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-7042
Practice Address - Country:US
Practice Address - Phone:312-996-2335
Practice Address - Fax:312-996-5921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0030401293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory