Basic Information
Provider Information | |||||||||
NPI: | 1760400170 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UIH-MILE SQUARE HEALTH CENTER AT SOUTH SHORE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1220 S. WOOD STREET | ||||||||
Address2: | UIH-MILE SQUARE HEALTH CENTER | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606081202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3124131261 | ||||||||
FaxNumber: | 3124137815 | ||||||||
Practice Location | |||||||||
Address1: | 7131 S. JEFFREY BLVD | ||||||||
Address2: | UIH-MILE SQUARE HEALTH CENTER AT SOUTH SHORE | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606492497 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732560526 | ||||||||
FaxNumber: | 3124137812 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 12/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAYLOR | ||||||||
AuthorizedOfficialFirstName: | HENRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3124131261 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | BCBS PROVIDER | 01 | IL | 1622185 | OTHER |