Organization
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Active
Organization
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Active
Other names
Mile Square-IHC Thresholds South
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM R. NICHOLAS PHD (EXECUTIVE DIRECTOR UIC MEDICAL PLAN)
(312) 413-0573
Entity
Organization
Contact information
Practice address
734 W 47TH ST, CHICAGO, IL 60609-4411
(312) 996-9354
(312) 996-7725
Mailing address
734 W 47TH ST, CHICAGO, IL 60609-4411
(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
—
01634874
BC/BS
IL
01
—
14-1072
MEDICARE CERTIFICATION
IL
Enumeration date
08/17/2006
Last updated
08/01/2008
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