Provider Demographics
NPI:1700832771
Name:BACHRACH, ETHAN ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ALLEN
Last Name:BACHRACH
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 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:509-942-2757
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044707207P00000X
ORMD27306207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0227894OtherLIWA
WA3075BAOtherBSWA
WA0202675OtherLIWA
OR041428016OtherBSOR
OR247610Medicaid
WA3079BAOtherBSWA
WA8429581Medicaid
WA0216266OtherLIWA
ID8077014Medicaid
WAP00289410Medicare PIN
WA0202675OtherLIWA
WA0216266OtherLIWA
WA8429581Medicaid