MEDICARE: NORTHWEST AMBUCARE

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	261QP1100X	Podiatric Clinic/Center

General Provider Information

NPI Number	:	1811965635
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST AMBUCARE

Provider Business Mailing Address
First Line	:	4040 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-6019
Country	:	US
Telephone Number	:	773-267-0554
Fax Number	:	773-267-6258

Provider Business Practice Location Address
First Line	:	4040 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-6019
Country	:	US
Telephone Number	:	773-267-0554
Fax Number	:	773-267-6258

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TEGAN AUGUSTINE THIMESCH
Credential	:	DPM
Telephone Number	:	773-267-0554

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	08/22/2020

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1013627322 — SAUGANASH SMILES PC
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Directions to “NORTHWEST AMBUCARE ” Practice Location

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