Provider Demographics
NPI:1992782494
Name:TICHO, BENJAMIN HENDRICK (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:HENDRICK
Last Name:TICHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10436 SOUTHWEST HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2284
Mailing Address - Country:US
Mailing Address - Phone:708-952-0109
Mailing Address - Fax:708-952-0329
Practice Address - Street 1:10436 SOUTHWEST HIGHWAY
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:708-423-4070
Practice Address - Fax:708-423-4216
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082457156FX1202X, 207WX0110X, 207W00000X
IN01070796A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric Technician
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBC/BS OF ILLINOIS
IL205786OtherPTAN MEDICARE DUPAGE COUNTY IL
IN253350OtherMEDICARE GROUP LEGACY LPI: 253350
IL036082457Medicaid
IL205785OtherPTAN MEDICARE COOK COUNTY IL
INM400068419OtherMEDICARE INDIVIDUAL PIN/PTAN: M400068419
IN10601008OtherCAQH
1083684922OtherGROUP NPI
IN200155690OtherINDIVIDUAL LEGACY PROVIDER
IN200155690OtherINDIANA MEDICAID
IL10601008OtherCAQH
IL180046211OtherMEDICARE RAILROAD
IN253350OtherMEDICARE GROUP LEGACY LPI: 253350
IL180046211OtherMEDICARE RAILROAD
IN200871680DOtherHINSDALE LOCATION 200871680D
IL205786OtherPTAN MEDICARE DUPAGE COUNTY IL
IL036082457Medicaid
IL6180260001Medicare NSC
ILL98635Medicare PIN