MEDICARE: MR. TEGAN AUGUSTINE THIMESCH I DPM

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	213ES0131X	Foot Surgery Podiatrist	016003998	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	60001565	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1376511287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TEGAN AUGUSTINE THIMESCH I DPM

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	02/26/2013

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