Healthcare Provider Details

I. General information

NPI: 1710289111
Provider Name (Legal Business Name): DENNIS T MANSHIO MD PHD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 S WABASH AVE STE 100A
CHICAGO IL
60616-3271
US

IV. Provider business mailing address

2907 S WABASH AVE STE 100A
CHICAGO IL
60616-3271
US

V. Phone/Fax

Practice location:
  • Phone: 773-477-3699
  • Fax: 312-877-5049
Mailing address:
  • Phone: 773-477-3699
  • Fax: 312-877-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036065850
License Number StateIL

VIII. Authorized Official

Name: DR. DENNIS MANSHIO
Title or Position: PRESIDENT
Credential: MD PHD
Phone: 773-477-3699