Healthcare Provider Details

I. General information

NPI: 1194842005
Provider Name (Legal Business Name): ANDREW JAY DENNIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1900 W POLK ST RM 1300
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-2730
  • Fax:
Mailing address:
  • Phone: 312-864-2730
  • Fax: 312-864-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number036-103297
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-103279
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036-103279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: