MEDICARE: DENNIS T MANSHIO MD PHD SC

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	207Q00000X	Family Medicine Physician	036065850	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	042617097	OTHER	IL	STATE OF ILLINOIS REGISTERED MEDICAL CORPORATION

General Provider Information

NPI Number	:	1710289111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENNIS T MANSHIO MD PHD SC

Provider Business Mailing Address
First Line	:	2907 S WABASH AVE STE 100A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3271
Country	:	US
Telephone Number	:	773-477-3699
Fax Number	:	312-877-5049

Provider Business Practice Location Address
First Line	:	2907 S WABASH AVE STE 100A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3271
Country	:	US
Telephone Number	:	773-477-3699
Fax Number	:	312-877-5049

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DENNIS MANSHIO
Credential	:	MD PHD
Telephone Number	:	773-477-3699

Provider Enumeration Date	:	11/17/2010
Last Update Date	:	10/30/2024

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