Provider Demographics
NPI:1194991216
Name:NORTHERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:NORTHERN ILLINOIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TO THE DEAN
Authorized Official - Prefix:
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-753-6161
Mailing Address - Street 1:3100 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9621
Mailing Address - Country:US
Mailing Address - Phone:815-752-2675
Mailing Address - Fax:815-753-6169
Practice Address - Street 1:3100 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9621
Practice Address - Country:US
Practice Address - Phone:815-752-2675
Practice Address - Fax:815-753-6169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012170261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1727Medicare PIN