NPIMap

Organization Active NPI

The Board of Trustees of the University of Illinois

Doing business as National Teachers Academy Clinic

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1356367304
Registry record updated Nov 14, 2024
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
National Teachers Academy Clinic
Practice address
55 W Cermak Rd
Chicago, IL 60616-2001
Phone
(312) 996-2000
Fax
(312) 413-1782
NPI assigned
Jul 14, 2006
Last updated
Nov 14, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOISAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 14, 2024

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

Authorized official

Name
Mr. Henry Taylor
Title
Executive Director
Phone
(312) 413-1261

Specialties & licenses 1

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

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 names 1

  • NATIONAL TEACHERS ACADEMY CLINIC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356367304. Details of each certification follow.

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
GovernmentNon-profit
Enrollment address
55 W Cermak Rd
Chicago, IL 60616-2001
Related CCNs
141896

Facilities connected through Provider of Services related, parent or unit certification numbers.

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

Other NPIs on the same Medicare enrollment 44

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 44

National Provider Directory

National Provider Directory
Tax ID family
U of I Opthalmology Dep122 organizations share this tax ID, including this one
Part of
U of I Opthalmology Dep

Organizations with this tax ID in the same state 24

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

View all 24

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 DirectorBoard Member-Treasurer Jan 16, 2018 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%
Amelia Filgham Individual Corporate DirectorBoard Member Sep 1, 2021 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 Aug 12, 2013 100%
Jeanette Moore Individual Corporate DirectorBoard Member Jan 1, 2004 100%
Carl Malone Individual Corporate DirectorBoard Member-President Jan 1, 2004 100%
Brian Townsend Individual Corporate DirectorBoard Member Sep 1, 2021 100%
Paul Ellinger Individual Corporate OfficerInterim Vice President, Chief Finan Aug 9, 2021 100%
Timothy Stecker Individual Corporate OfficerChief Financial Officer Nov 1, 2024 100%
W-2 Managing EmployeeAd; May 1, 2018 100%
Randall Harris Individual Corporate DirectorBoard Member-Vice President Jan 1, 2003 100%
Mattie Williams Individual Corporate DirectorBoard Member-Secretary Jan 1, 2005 100%
Martha Valdez Individual Corporate DirectorBoard Member May 12, 2014 100%

All facility ownership & control disclosures 11

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
Ui Health Mile Square Health Center Back of the Yards DentalChicago, IL, CCN 781067 Federally qualified health center 5% Or Greater Indirect Ownership Interest (100%) Feb 1, 2022

Owned or controlled facilities with NPI records 11

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

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

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

{
    "created_epoch": "1152835200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731542400000",
    "number": "1356367304",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2045 W WASHINGTON BLVD",
            "address_2": "M/C 698",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606122428",
            "telephone_number": "312-996-2000",
            "fax_number": "312-413-1782"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "55 W CERMAK RD",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606162001",
            "telephone_number": "312-996-2000",
            "fax_number": "312-413-1782"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS",
        "enumeration_date": "2006-07-14",
        "last_updated": "2024-11-14",
        "certification_date": "2024-11-14",
        "status": "A",
        "authorized_official_last_name": "TAYLOR",
        "authorized_official_first_name": "HENRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "312-413-1261",
        "authorized_official_name_prefix": "Mr."
    },
    "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": "NATIONAL TEACHERS ACADEMY CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.