Provider Demographics
NPI:1720513906
Name:UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER
Entity type:Organization
Organization Name:UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HUNTINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-863-7795
Mailing Address - Street 1:1203 E BRIGHTWATER LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6718
Mailing Address - Country:US
Mailing Address - Phone:208-863-7795
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007222261QM1300X, 273100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No273100000XHospital UnitsEpilepsy Unit