Basic Information
| Provider Information | |||||||||
| NPI: | 1336488055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE BOARD OF TRUSTEES OF UNIVERSITY OF ILLINOIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UIC EMERGENCY MEDICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1368 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601268368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305302988 | ||||||||
| FaxNumber: | 6308329750 | ||||||||
| Practice Location | |||||||||
| Address1: | 1129 S HERMITAGE AVE | ||||||||
| Address2: | ROOM 101 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123554367 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2013 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | ROY | ||||||||
| AuthorizedOfficialTitleorPosition: | EMS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3123554367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BS, NRP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 11 8150 | IL | Y | Transportation Services | Ambulance |
No ID Information.