1497923767 NPI number — UNIVERSITY OF ILLINOIS SPEECH AND HEARING

Table of content: (NPI 1497923767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497923767 NPI number — UNIVERSITY OF ILLINOIS SPEECH AND HEARING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF ILLINOIS SPEECH AND HEARING
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:
SPEECH-LANGUAGE PATHOLOGY CLINIC
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:
1497923767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 S OAK ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61820-0906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-333-2205
Provider Business Mailing Address Fax Number:
217-333-2206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 S OAK ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-0906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-333-2205
Provider Business Practice Location Address Fax Number:
217-333-2206
Provider Enumeration Date:
02/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MENDES
Authorized Official First Name:
CLARION
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CLINICAL EDUCATION
Authorized Official Telephone Number:
217-333-2205

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  146003459 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: 146008043 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 146004209 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 146000794 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 146005525 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 328742120001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344384568001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 399620438001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 356589993001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 386640092001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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