Basic Information
Provider Information | |||||||||
NPI: | 1700832771 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BACHRACH | ||||||||
FirstName: | ETHAN | ||||||||
MiddleName: | ALLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 505 S 336TH ST | ||||||||
Address2: | SUITE 600 | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980036328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538386180 | ||||||||
FaxNumber: | 2538386418 | ||||||||
Practice Location | |||||||||
Address1: | 888 SWIFT BLVD | ||||||||
Address2: |   | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 993523514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099464611 | ||||||||
FaxNumber: | 5099422757 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2006 | ||||||||
LastUpdateDate: | 10/26/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00044707 | WA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD27306 | OR | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0227894 | 01 | WA | LIWA | OTHER | 3075BA | 01 | WA | BSWA | OTHER | 0202675 | 01 | WA | LIWA | OTHER | 041428016 | 01 | OR | BSOR | OTHER | 247610 | 05 | OR |   | MEDICAID | 3079BA | 01 | WA | BSWA | OTHER | 8429581 | 05 | WA |   | MEDICAID | 0216266 | 01 | WA | LIWA | OTHER | 8077014 | 05 | ID |   | MEDICAID |