Basic Information
| Provider Information | |||||||||
| NPI: | 1124430459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACHMAN | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHLABACH | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2120 RIETH BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465265858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748755126 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2014 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO181076 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 02004724A | IN | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 02004724A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 236040380 | 01 | IN | MEDICARE PTAN | OTHER | 201231260 | 05 | IN | MEDICAID |