Basic Information
| Provider Information | |||||||||
| NPI: | 1245435361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF ILLINOIS AT CHICAGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 W 64TH ST | ||||||||
| Address2: | |||||||||
| City: | WILLOWBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605275304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125023004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1740 W TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606127232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | WU | ||||||||
| AuthorizedOfficialFirstName: | SHOUJIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | FACULTY | ||||||||
| AuthorizedOfficialTelephone: | 3125023004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 036087484 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
No ID Information.