Provider Demographics
NPI:1578724753
Name:UNIVERSITY OF ILLINOIS URBANA-CHAMPAIGN
Entity type:Organization
Organization Name:UNIVERSITY OF ILLINOIS URBANA-CHAMPAIGN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, MCKINLEY HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:AWAIS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-333-2711
Mailing Address - Street 1:1109 S LINCOLN AVE
Mailing Address - Street 2:MC-026
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-4703
Mailing Address - Country:US
Mailing Address - Phone:217-333-2711
Mailing Address - Fax:217-244-1758
Practice Address - Street 1:1109 S LINCOLN AVE
Practice Address - Street 2:MC-026
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-4703
Practice Address - Country:US
Practice Address - Phone:217-333-2711
Practice Address - Fax:217-244-1758
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIV. OF ILLINOIS URBANA-CHAMPAIGN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-20
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105311261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1174539737OtherFOR THIRD PARTY
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IL1932109113OtherFOR THIRD PARTY
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IL1619030798OtherFOR THIRD PARTY
IL1821013939OtherFOR THIRD PARTY
IL1932279742OtherFOR THIRD PARTY
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IL1861416455OtherFOR THIRD PARTY
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IL1922199900OtherFOR THIRD PARTY
IL1962570721OtherFOR THIRD PARTY