Provider Demographics
NPI:1881919736
Name:BACHTA, KELLY E R (MD, PHD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E R
Last Name:BACHTA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE #1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:SUITE #1000
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:312-695-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA255013207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program