Organization
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Active
Other names
Mile Square- IHC Thresholds Mothers Program
Organization subpart
No
Provider details
NPI number
Authorized official
DR. WILLIAM R NICOLAS PHD (EXECUTIVE DIRECTOR UIC MEDICAL PLA)
(312) 413-0573
Entity
Organization
Contact information
Practice address
1110 W BELMONT AVE, IHC THRESHOLDS MOTHERS PROGRAM, CHICAGO, IL 60657-3313
(312) 996-9354
(312) 996-7725
Mailing address
1110 W BELMONT AVE, IHC THRESHOLDS MOTHERS PROGRAM, CHICAGO, IL 60657-3313
(312) 996-9354
(312) 996-7725
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14-1073
MEDICARE CERTIFICATION
IL
Enumeration date
09/20/2007
Last updated
08/05/2008
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