MEDICARE: ENRIQUE CORNEJO CISNEROS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2011015465	MO
2	207RI0200X	Infectious Disease Physician	125.064371	IL

General Provider Information

NPI Number	:	1164719357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENRIQUE CORNEJO CISNEROS M.D.

Provider Business Mailing Address
First Line	:	441 E ERIE ST APT 3205
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4429
Country	:	US
Telephone Number	:	314-560-2165
Fax Number	:

Provider Business Practice Location Address
First Line	:	441 E ERIE ST APT 3205
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4429
Country	:	US
Telephone Number	:	314-560-2165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2011
Last Update Date	:	07/21/2022

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