The Board of Trustees of the University of Illinois
Organization Active NPI Federally Qualified Health Center (FQHC) · Chicago, IL
NPI 1356367304 · NPPES record last updated Nov 14, 2024
Key facts
- NPI
- 1356367304
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
- Practice address
- 55 W Cermak Rd
Chicago, IL 60616-2001 - Phone
- (312) 996-2000
- Fax
- (312) 413-1782
- NPI assigned
- Jul 14, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Authorized official
- Name
- Mr. Henry Taylor
- Title
- Executive Director
- Phone
- (312) 413-1261
Owned or controlled facilities with NPI records 11
Other NPIs on the same Medicare enrollment 44
Other NPIs with the same Medicare PAC ID 23
Corporate family (same tax ID) 24
Related certifications (CCN) 1
Practitioners 1,146
-
Therese Marie Doyle, CNM
-
Nicole Michele Gastala, M.D.
-
Alexandra Leigh Aaronson, M.D.
-
Motaz Abas, MD
-
Khaled Abdelhady, M.D.
-
Rohit Abraham, MD, MPH, MAT
-
Omer Acar, MD
-
Elenmor Achurra, DNP, APRN, PMHNP-BC
-
Jessica Acosta, APRN
-
Lisa Marie Adiutori, D.O.
-
Mitra Afshari, M.D. M.P.H
-
Lorraine Aguada, NP
-
Aneet Ahluwalia, M.D.
-
Jamal Ahmad, M.D.
-
Zohair Ahmed, M.D.
-
Aleena Aickareth, APN-CNP
-
Olusola A. Ajilore, M.D.
-
Abayomi Akintorin, M.D.
-
Osama Al Deyabat, MBBS
-
Peter Alahi, MD
-
Ali Alaraj, M.D
-
Cecilia Anne Albaro, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IL
Federally qualified health center certification: CCN 781830
- Legal name
- THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
- Doing business as
- MILE SQUARE NATIONAL TEACHERS ACADEMY CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Nov 20, 2014
- Last certification
- Nov 20, 2014
- Ownership / control type
- For profit – corporation
- Organization structure
- Government · Non-profit
- Enrollment address
- 55 W Cermak Rd
Chicago, IL 60616-2001 - Related CCNs
- 141896
All disclosed owners & managing parties 16
| Name | Role | Since | Share |
|---|---|---|---|
| John Bolden |
Corporate Director |
Jan 16, 2018 | 100% |
| Carol Gyimatey |
Corporate Director |
Jan 16, 2018 | 100% |
| Gloria Riley |
Corporate Director |
Jan 1, 2005 | 100% |
| Beverly Echols |
Corporate Director |
Aug 1, 2012 | 100% |
| Amelia Filgham |
Corporate Director |
Sep 1, 2021 | 100% |
| Dennis Harezlak |
Corporate Director |
May 1, 2020 | 100% |
| Richard Boykin |
Corporate Director |
Jan 16, 2018 | 100% |
| Clarence Long |
Corporate Director |
Aug 12, 2013 | 100% |
| Jeanette Moore |
Corporate Director |
Jan 1, 2004 | 100% |
| Carl Malone |
Corporate Director |
Jan 1, 2004 | 100% |
| Brian Townsend |
Corporate Director |
Sep 1, 2021 | 100% |
| Paul Ellinger |
Corporate Officer |
Aug 9, 2021 | 100% |
| Timothy Stecker |
Corporate Officer |
Nov 1, 2024 | 100% |
| W-2 Managing Employee |
May 1, 2018 | 100% | |
| Randall Harris |
Corporate Director |
Jan 1, 2003 | 100% |
| Mattie Williams |
Corporate Director |
Jan 1, 2005 | 100% |
| Martha Valdez |
Corporate Director |
May 12, 2014 | 100% |
All facility ownership & control disclosures 11
| Facility | Type | Role | Since |
|---|---|---|---|
| University of Illinois Hospital and Clinics |
Hospital | Operational/Managerial Control (100%) | Jul 1, 1966 |
| University of Illinois Hospital |
Hospital | Operational/Managerial Control (100%) | Jul 1, 1966 |
| Uimcc MSHC at South Shore |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Aug 1, 2012 |
| Uic Mile Square Health Center |
Federally qualified health center | Operational/Managerial Control (100%) | Jul 2, 2012 |
| Mile Square Back of the Yards |
Federally qualified health center | 5% Or Greater Indirect Ownership Interest (100%) | Apr 10, 2008 |
| Uic-Mile Square at Cicero |
Federally qualified health center | 5% Or Greater Indirect Ownership Interest (100%) | Nov 10, 2010 |
| University of Illinois - Mile Square Health Center Englewood |
Federally qualified health center | 5% Or Greater Indirect Ownership Interest (100%) | Jul 2, 2012 |
| Mile Square Davis Health and Wellness Center |
Federally qualified health center | 5% Or Greater Indirect Ownership Interest (100%) | Oct 1, 2015 |
| The Board of Trustees of the University of Illinois |
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 Center |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Feb 1, 2022 |
| Ui Health Mile Square Health Center Back of the Yards Dental |
Federally qualified health center | 5% Or Greater Indirect Ownership Interest (100%) | Feb 1, 2022 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031112000158 | IL | Part B Supplier - Clinic/Group Practice | 3072422716 |
Receives reassigned benefits from 2,115 practitioners 44 other NPIs on this enrollment This NPI is an additional NPI on the enrollment |
| O20141027001730 | IL | Part a Provider - Federally Qualified Health Center (FQHC) | 3072422716 | Practice locations: Chicago, IL |
National Provider Directory
- Tax ID family
- Univ of Illinois Hospit
- Part of
- Univ of Illinois Hospit
Locations
1919 W Taylor St
Chicago, IL 60612
Phone (312) 996-2901
3050 W 39th Pl
Chicago, IL 60632
Phone (773) 376-8008
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
55 W Cermak Rd
Chicago, IL 60616-2001
Mailing address
2045 W Washington Blvd
M/C 698
Chicago, IL 60612-2428
Phone (312) 996-2000
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1622185 | Other | BCBS PROVIDER ID |
Other names
- NATIONAL TEACHERS ACADEMY CLINIC
Other providers in Chicago, IL
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
- The Board of Trustees of the University of Illinois
All providers in Chicago, IL · Federally Qualified Health Center (FQHC) in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 14, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.