Basic Information
| Provider Information | |||||||||
| NPI: | 1407835309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACH | ||||||||
| FirstName: | BERNARD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
| Address2: | #240 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1611 W HARRISON ST | ||||||||
| Address2: | # 400 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122434244 | ||||||||
| FaxNumber: | 3129421517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 036073187 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4028377 | 01 | AETNA | OTHER | 1633878 | 01 | IL | BCBS | OTHER | 207073 | 01 | IL | MEDICARE PTAN LOCALITY 15 | OTHER | 207067 | 01 | IL | MEDICARE PTAN LOCALITY 16 | OTHER | P00095130 | 01 | RAILROAD MEDICARE | OTHER | DA4902 | 01 | RAILROAD MEDICARE PTAN | OTHER | 036073187 | 05 | IL | MEDICAID |