NPIMap

Organization Active NPI

The Board of Trustees of the University of Illinois

Doing business as UIC,Mile Square Health Center,Davis Health and Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1932450160
Registry record updated Oct 15, 2020
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
UIC,Mile Square Health Center,Davis Health and Wellness Center
Practice address
3050 W 39TH PL
Chicago, IL 60632-2402
Phone
(312) 413-1261
Fax
(312) 413-7812
NPI assigned
Sep 27, 2012
Last updated
Oct 15, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 15, 2020

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

3050 W 39TH PL
Chicago, IL 60632-2402

Mailing address

2045 W Washington Blvd
Chicago, IL 60612-2428
Phone (312) 413-1261

Other identifiers 1

IdentifierTypeStateIssuer
1622185OtherILBLUE CROSS

Other names 1

  • UIC,Mile Square Health Center,Davis Health and Wellness Center 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
O20151103002151 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 1932450160. Details of each certification follow.

Federally qualified health center certification: CCN 781842

Legal name
THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Doing business as
MILE SQUARE DAVIS HEALTH AND WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 24, 2015
Last certification
Nov 24, 2015
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 1, 1941 in IL
Enrollment address
3050 W 39TH PL
Chicago, IL 60632-2402

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

Ownership & related parties

All disclosed owners & managing parties 18

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 Jan 1, 2002 100%
Carol Gyimatey Individual Corporate DirectorBoard Member Jan 16, 2018 100%
Gloria Riley Individual OtherBoard Member Jan 1, 2005
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 1, 2010 100%
Henry Taylor Individual W-2 Managing EmployeeExecutive Director Aug 14, 1998
Clarence Long Individual Corporate DirectorBoard Member Aug 12, 2013 100%
Jeanette Moore Individual OtherBoard Member Jan 1, 2003
Carl Malone Individual OtherBoard Member - Vice President Jan 1, 2004
The Board of Trustees of the University of Illinois Organization, Chicago, IL 5% Or Greater Indirect Ownership Interest Oct 1, 2015 100%
Brian Townsend Individual Corporate DirectorBoard Member Sep 1, 2021 100%
Paul Ellinger Individual Corporate DirectorInterim Vice President Chief Finan Aug 9, 2021 100%
Elizabeth Duarte Individual Corporate DirectorBoard Member May 1, 2020 100%
Randall Harris Individual Corporate DirectorBoard Member Jan 1, 2003 100%
Mattie Williams Individual Corporate DirectorBoard Member Jan 1, 2004 100%
Martha Valdez Individual Corporate DirectorBoard Member May 12, 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
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 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.

Practitioners & affiliated clinicians

Practitioners 9

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.

NPI Registry JSON

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

{
    "created_epoch": "1348704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602720000000",
    "number": "1932450160",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2045 W WASHINGTON BLVD",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606122428",
            "telephone_number": "312-413-1261",
            "fax_number": "312-413-7812"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3050 W 39TH PL",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606322402",
            "telephone_number": "312-413-1261",
            "fax_number": "312-413-7812"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-27",
        "last_updated": "2020-10-15",
        "certification_date": "2020-10-15",
        "status": "A",
        "authorized_official_last_name": "TAYLOR",
        "authorized_official_first_name": "HENRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "312-312-1261",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CEO"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "1622185",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "UIC,Mile Square Health Center,Davis Health and Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "UIC,Mile Square Health Center,Davis Health and Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.