Provider Demographics
NPI:1780990051
Name:NORTHERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:NORTHERN ILLINOIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ATHLETIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:VOORHIS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:815-753-0211
Mailing Address - Street 1:1525 W LINCOLN HWY
Mailing Address - Street 2:SUITE 170-NIU ATHLETIC TRAINING
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3989
Mailing Address - Country:US
Mailing Address - Phone:815-753-0211
Mailing Address - Fax:815-753-1402
Practice Address - Street 1:1525 W LINCOLN HWY
Practice Address - Street 2:SUITE 170-NIU ATHLETIC TRAINING
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3989
Practice Address - Country:US
Practice Address - Phone:815-753-0211
Practice Address - Fax:815-753-1402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096000344261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation