1205022506 NPI number — THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Table of content: (NPI 1205022506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205022506 NPI number — THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE BOARD OF TRUSTEES OF 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:
Provider Other Organization Name Type Code:
6
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:
1205022506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 W BELMONT AVE
Provider Second Line Business Mailing Address:
IHC THRESHOLDS MOTHERS PROGRAM
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60657-3313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-996-9354
Provider Business Mailing Address Fax Number:
312-996-7725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 W BELMONT AVE
Provider Second Line Business Practice Location Address:
IHC THRESHOLDS MOTHERS PROGRAM
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60657-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-9354
Provider Business Practice Location Address Fax Number:
312-996-7725
Provider Enumeration Date:
09/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NICOLAS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
EXECUTIVE DIRECTOR UIC MEDICAL PLA
Authorized Official Telephone Number:
312-413-0573

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14-1073 . This is a "MEDICARE CERTIFICATION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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