Provider Demographics
NPI:1043794506
Name:SUBURBAN EYE SPECIALISTS
Entity Type:Organization
Organization Name:SUBURBAN EYE SPECIALISTS
Other - Org Name:TICHO EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TICHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-586-4922
Mailing Address - Street 1:10436 SOUTHWEST HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2282
Mailing Address - Country:US
Mailing Address - Phone:708-586-4922
Mailing Address - Fax:
Practice Address - Street 1:10436 SOUTHWEST HWY STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2282
Practice Address - Country:US
Practice Address - Phone:708-586-4922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL300622839Medicaid
IN300016721Medicaid