Provider Demographics
NPI:1093799603
Name:BACHENBERG, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BACHENBERG
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:PO BOX 800
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8555
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN06Q36BAOtherBLUE CROSS
MN7293OtherAVERA
MN23346OtherSIOUX VALLEY
MN604566OtherARAZ
MNHP29866OtherHEALTHPARTNERS
MN01-13050OtherMEDICA
MN06Q36BAMedicaid
MN120541Medicaid
IA983395Medicaid
MNMH9041001734OtherPREFERREDONE
MN762580400Medicaid
MNA021OtherCHAMPUS
E97095Medicare UPIN
MN06Q36BAMedicare ID - Type UnspecifiedBC MEDICARE SUPPLEMENT
IA983395Medicaid
MNHP29866OtherHEALTHPARTNERS
MN604566OtherARAZ