Provider Demographics
NPI:1376511287
Name:THIMESCH, TEGAN AUGUSTINE I (DPM)
Entity Type:Individual
Prefix:MR
First Name:TEGAN
Middle Name:AUGUSTINE
Last Name:THIMESCH
Suffix:I
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6019
Mailing Address - Country:US
Mailing Address - Phone:773-267-0554
Mailing Address - Fax:773-267-6258
Practice Address - Street 1:4040 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6019
Practice Address - Country:US
Practice Address - Phone:773-267-0554
Practice Address - Fax:773-267-6258
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003998213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60001565OtherBCBS
IL764040Medicare ID - Type Unspecified
ILT38733Medicare UPIN