1174554331 NPI number — UNIVERSITY OF ILLINOIS - CHICAGO

Table of content: (NPI 1174554331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174554331 NPI number — UNIVERSITY OF ILLINOIS - CHICAGO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF ILLINOIS - CHICAGO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COLLEGE OF APPLIED HEALTH SCIENCES FACULTY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174554331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5254 SOLUTION CENTER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-413-1567
Provider Business Mailing Address Fax Number:
312-413-1993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 W ROOSEVELT RD
Provider Second Line Business Practice Location Address:
ROOM 336 (MC 628)
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608-1316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-413-1567
Provider Business Practice Location Address Fax Number:
312-413-1993
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FERNHALL
Authorized Official First Name:
BO
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
312-413-1567

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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