Basic Information
| Provider Information | |||||||||
| NPI: | 1871905190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY CLINIC AT SOUTH BELOIT - JUNIOR HIGH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955861 | ||||||||
| FaxNumber: | 8153955575 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 BLACKHAWK BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BELOIT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610802263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955861 | ||||||||
| FaxNumber: | 8153955575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2014 | ||||||||
| LastUpdateDate: | 05/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | HARNER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCIAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 8153955637 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | IL | MEDICAID |