Healthcare Provider Details

I. General information

NPI: 1154960813
Provider Name (Legal Business Name): DENNIS SHEA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2019
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E ONTARIO ST STE 200
CHICAGO IL
60611-3284
US

IV. Provider business mailing address

211 E ONTARIO ST STE 200
CHICAGO IL
60611-3284
US

V. Phone/Fax

Practice location:
  • Phone: 312-694-7000
  • Fax: 312-926-6274
Mailing address:
  • Phone: 312-694-7000
  • Fax: 312-926-6274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008502
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: