Basic Information
| Provider Information | |||||||||
| NPI: | 1871811786 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UIC PATHOLOGY CLINICAL LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2723 SOLUTION CENTER | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967312 | ||||||||
| FaxNumber: | 3129967586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 W. TAYLOR STREET | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967312 | ||||||||
| FaxNumber: | 3129967586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2010 | ||||||||
| LastUpdateDate: | 05/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | PREYAL | ||||||||
| AuthorizedOfficialMiddleName: | ANKIT | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMINISTRATIVE OPERATIO | ||||||||
| AuthorizedOfficialTelephone: | 3129962135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
No ID Information.