NPIMap

Organization Active NPI

The Board of Trustees of the University of Illinois

Doing business as UI Health Mile Square Health Center Back of the Yards Dental

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1124787908
Registry record updated Jun 27, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Doing business as
UI Health Mile Square Health Center Back of the Yards Dental
Practice address
4634 S Bishop St
Chicago, IL 60609-3240
Phone
(312) 355-5570
NPI assigned
Dec 9, 2021
Last updated
Jun 27, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOISAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 27, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy Stecker
Title
Cfo
Phone
(312) 355-7653

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

4634 S Bishop St
Chicago, IL 60609-3240

Mailing address

1220 S Wood St
Chicago, IL 60608-1202
Phone (312) 413-3282

Other names 1

  • UI Health Mile Square Health Center Back of the Yards Dental Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220711002856 IL Part A Provider - Federally Qualified Health Center (FQHC) 3072422716 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124787908. Details of each certification follow.

Federally qualified health center certification: CCN 781067

Legal name
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Doing business as
UI HEALTH MILE SQUARE HEALTH CENTER BACK OF THE YARDS DENTAL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 3, 2022
Last certification
May 3, 2022
Ownership / control type
For profit – corporation
Organization structure
GovernmentNon-profit
Incorporated
Feb 1, 2022 in IL
Enrollment address
4634 S Bishop St
Chicago, IL 60609-3240

Other NPIs with the same Medicare PAC ID 23

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 23

National Provider Directory

National Provider Directory
Tax ID family
Univ of Illinois Emerg122 organizations share this tax ID, including this one
Part of
Univ of Illinois Emerg

Organizations with this tax ID in the same state 23

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 23

Ownership & related parties

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
John Bolden Individual Corporate DirectorTreasurer Board Member Jan 1, 2010 100%
Carol Gyimatey Individual Corporate DirectorBoard Member Jan 16, 2018 100%
Gloria Riley Individual Corporate DirectorBoard Member Jan 1, 2005 100%
Beverly Echols Individual Corporate DirectorBoard Member Aug 1, 2012 100%
Dennis Harezlak Individual Corporate DirectorBoard Member May 1, 2020 100%
Richard Boykin Individual Corporate DirectorBoard Member Jan 16, 2018 100%
Clarence Long Individual Corporate DirectorBoard Member Jan 1, 2013 100%
Jeanette Moore Individual Corporate DirectorBoard Member Jan 1, 2004 100%
Carl Malone Individual Corporate DirectorPresident Board Member Jan 1, 2004 100%
The Board of Trustees of the University of Illinois Organization, Chicago, IL 5% Or Greater Indirect Ownership Interest Feb 1, 2022 100%
Paul Ellinger Individual Corporate DirectorInterim Vice President, Chief Finan Aug 1, 2021 100%
Timothy Stecker Individual Corporate OfficerChief Financial Officer Oct 24, 2024 100%
W-2 Managing EmployeeCfo May 1, 2018 100%
Elizabeth Duarte Individual Corporate DirectorBoard Member May 1, 2020 100%
Randall Harris Individual Corporate DirectorVice President Board Member Jan 1, 2003 100%
Mattie Williams Individual Corporate DirectorSecretary-Board Member Jan 1, 2005 100%
Martha Valdez Individual Corporate OfficerBoard Member Jan 16, 2014 100%

Owners & managing parties with NPI records 23

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 23

All facility ownership & control disclosures 10

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
University of Illinois Hospital and ClinicsChicago, IL, CCN 140150 Hospital Operational/Managerial Control (100%) Jul 1, 1966
University of Illinois HospitalChicago, IL, CCN 14S150 Hospital Operational/Managerial Control (100%) Jul 1, 1966
Uimcc MSHC at South ShoreChicago, IL, CCN 141028 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Aug 1, 2012
Uic Mile Square Health CenterChicago, IL, CCN 141896 Federally qualified health center Operational/Managerial Control (100%) Jul 2, 2012
Mile Square Back of the YardsChicago, IL, CCN 141074 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%) Apr 10, 2008
Uic-Mile Square at CiceroCicero, IL, CCN 141161 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%) Nov 10, 2010
University of Illinois - Mile Square Health Center EnglewoodChicago, IL, CCN 141175 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%) Jul 2, 2012
Mile Square Davis Health and Wellness CenterChicago, IL, CCN 781842 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%) Oct 1, 2015
The Board of Trustees of the University of IllinoisRockford, IL, CCN 781936 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%)
Operational/Managerial Control (100%)		 May 9, 2020
May 9, 2020
Ui Health Mile Square Health Center Primary and Immediate Care CenterChicago, IL, CCN 781070 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Feb 1, 2022

Owned or controlled facilities with NPI records 10

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 10

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1639008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750982400000",
    "number": "1124787908",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1220 S WOOD ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606081202",
            "telephone_number": "312-413-3282"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4634 S BISHOP ST",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606093240",
            "telephone_number": "312-355-5570"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS",
        "enumeration_date": "2021-12-09",
        "last_updated": "2025-06-27",
        "certification_date": "2025-06-27",
        "status": "A",
        "authorized_official_last_name": "STECKER",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "312-355-7653"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "UI Health Mile Square Health Center Back of the Yards Dental",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "UI Health Mile Square Health Center Back of the Yards Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.