Basic Information
| Provider Information | |||||||||
| NPI: | 1760421705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 S MARSHFIELD AVE | ||||||||
| Address2: | 9TH FLOOR (M/C 732) | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129961000 | ||||||||
| FaxNumber: | 3129961001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 W TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606127232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967699 | ||||||||
| FaxNumber: | 3129961001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNORR | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CFO, COMPTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 3129968800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.