Provider Demographics
NPI:1710289111
Name:DENNIS T MANSHIO MD PHD SC
Entity type:Organization
Organization Name:DENNIS T MANSHIO MD PHD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSHIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:773-477-3699
Mailing Address - Street 1:2907 S WABASH AVE STE 100A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3271
Mailing Address - Country:US
Mailing Address - Phone:773-477-3699
Mailing Address - Fax:312-877-5049
Practice Address - Street 1:2907 S WABASH AVE STE 100A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3271
Practice Address - Country:US
Practice Address - Phone:773-477-3699
Practice Address - Fax:312-877-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042617097OtherSTATE OF ILLINOIS REGISTERED MEDICAL CORPORATION