Provider Demographics
NPI:1497498315
Name:BACH, KATHY (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:BACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 UNIVERSITY ROW
Mailing Address - Street 2:STE 200
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705
Mailing Address - Country:US
Mailing Address - Phone:608-263-6400
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:GME ADMIN - SECOND FLOOR - SURGERY
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-373-5941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN11023184A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program