Healthcare Provider Details

I. General information

NPI: 1376511287
Provider Name (Legal Business Name): TEGAN AUGUSTINE THIMESCH I DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 W PETERSON AVE
CHICAGO IL
60646-6019
US

IV. Provider business mailing address

4040 W PETERSON AVE
CHICAGO IL
60646-6019
US

V. Phone/Fax

Practice location:
  • Phone: 773-267-0554
  • Fax: 773-267-6258
Mailing address:
  • Phone: 773-267-0554
  • Fax: 773-267-6258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016003998
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: