Provider Demographics
NPI:1902932825
Name:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type:Organization
Organization Name:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Other - Org Name:UNIVERSITY OF ILLINOIS TAYLOR ST. / EEI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, CFO, COMPTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:K
Authorized Official - Last Name:KNORR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-996-8800
Mailing Address - Street 1:840 S WOOD ST
Mailing Address - Street 2:SUITE 345 CSB, MC 884
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-2812
Mailing Address - Fax:312-355-1916
Practice Address - Street 1:1855 W TAYLOR ST
Practice Address - Street 2:SUITE 1071
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7242
Practice Address - Country:US
Practice Address - Phone:312-996-6540
Practice Address - Fax:312-996-1314
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-26
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL93009390332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0582290005Medicare NSC