Provider Demographics
NPI:1184899775
Name:BACHRACH, LAURIE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:
Last Name:BACHRACH
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 1:675 W NORTH AVE
Mailing Address - Street 2:STE. 605
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-450-5055
Mailing Address - Fax:708-338-2474
Practice Address - Street 1:501 W NORTH AVE STE 201
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1600
Practice Address - Country:US
Practice Address - Phone:708-450-5055
Practice Address - Fax:708-338-2474
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129549208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F400140262Medicare PIN
F400140259Medicare PIN
5514060013Medicare NSC