Organization
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Active
Other names
UIC,Mile Square Health Center,Davis Health and Wellness Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. HENRY TAYLOR CEO (EXECUTIVE DIRECTOR)
(312) 312-1261
Entity
Organization
Contact information
Practice address
3050 W 39TH PL, CHICAGO, IL 60632-2402
(312) 413-1261
(312) 413-7812
Mailing address
2045 W WASHINGTON BLVD, CHICAGO, IL 60612-2428
(312) 413-1261
(312) 413-7812
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1622185
BLUE CROSS
IL
Enumeration date
09/27/2012
Last updated
10/15/2020
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