1578039939 NPI number — BOARD OF TRUSTEES FO THE UNIVERSITY OF ILLINOIS

Table of content: (NPI 1578039939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578039939 NPI number — BOARD OF TRUSTEES FO THE UNIVERSITY OF ILLINOIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOARD OF TRUSTEES FO THE UNIVERSITY OF ILLINOIS
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:
UIH-MILE SQUARE HEALTH CENTER AT BACK OF THE YARDS IHH
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:
1578039939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 S WOOD ST
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:
60608-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-413-1261
Provider Business Mailing Address Fax Number:
312-413-7812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 S BISHOP ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60609-3240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-579-9401
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
312-413-1261

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1622185 . This is a "BCBS PROVIDER" identifier . This identifiers is of the category "OTHER".




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