Basic Information
| Provider Information | |||||||||
| NPI: | 1043510241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UIC-MSHC HOPE ACADEMY HEALTH AND WELLNESS CTR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2045 W WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606122428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124139854 | ||||||||
| FaxNumber: | 3124137812 | ||||||||
| Practice Location | |||||||||
| Address1: | 1628 W WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606122613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122263288 | ||||||||
| FaxNumber: | 3122263541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2010 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3124131261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1622185 | 01 | IL | BCBC PROVIDER | OTHER |