Basic Information
| Provider Information | |||||||||
| NPI: | 1346596327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UIH-MILE SQUARE HEALTH CENTER AT ENGLEWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 S. WOOD STREET | ||||||||
| Address2: | UIH-MILE SQUARE HEALTH CENTER | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606081202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124131261 | ||||||||
| FaxNumber: | 3124137812 | ||||||||
| Practice Location | |||||||||
| Address1: | 641 W. 63RD ST | ||||||||
| Address2: | UIH-MILE SQUARE HEALTH CENTER AT ENGLEWOOD | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606212032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124134070 | ||||||||
| FaxNumber: | 3124137812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2012 | ||||||||
| LastUpdateDate: | 12/17/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3124131261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1622185 | 01 | IL | BLUE CROSS | OTHER | 1622185 | 01 | IL | BCBS PROVIDER | OTHER |