MEDICARE: BENJAMIN HENDRICK TICHO MD

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	156FX1202X	Optometric Technician	036082457	IL
2	207W00000X	Ophthalmology Physician	01070796A	IN
3	207WX0110X	Pediatric Ophthalmology and Strabismus Specialist Physician Physician	036082457	IL
4	207W00000X	Ophthalmology Physician	036082457	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	205786	OTHER	IL	PTAN MEDICARE DUPAGE COUNTY IL
3	253350	OTHER	IN	MEDICARE GROUP LEGACY LPI: 253350
5	205785	OTHER	IL	PTAN MEDICARE COOK COUNTY IL
6	M400068419	OTHER	IN	MEDICARE INDIVIDUAL PIN/PTAN: M400068419
12	180046211	OTHER	IL	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01621679	OTHER	IL	BC/BS OF ILLINOIS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	10601008	OTHER	IN	CAQH
8	1083684922	OTHER		GROUP NPI
9	200155690	OTHER	IN	INDIVIDUAL LEGACY PROVIDER
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	10601008	OTHER	IL	CAQH

General Provider Information

NPI Number	:	1992782494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN HENDRICK TICHO MD

Provider Business Mailing Address
First Line	:	10436 SOUTHWEST HWY STE 1
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2284
Country	:	US
Telephone Number	:	708-952-0109
Fax Number	:	708-952-0329

Provider Business Practice Location Address
First Line	:	10436 SOUTHWEST HIGHWAY
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2282
Country	:	US
Telephone Number	:	708-423-4070
Fax Number	:	708-423-4216

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	04/23/2020

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