Basic Information
Provider Information | |||||||||
NPI: | 1174605364 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENTLEY | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | ERIC | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1878 OLD LEBANON RD | ||||||||
Address2: |   | ||||||||
City: | CAMPBELLSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 427189663 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704657505 | ||||||||
FaxNumber: | 2707893860 | ||||||||
Practice Location | |||||||||
Address1: | 1878 OLD LEBANON RD | ||||||||
Address2: |   | ||||||||
City: | CAMPBELLSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 427189663 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704657505 | ||||||||
FaxNumber: | 2707893860 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 01/17/2008 | ||||||||
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 | 208600000X | 24667 | KY | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | BB 0485525 | 01 | KY | DEA NUMBER | OTHER | 48C4 | 01 | KY | BC/BS | OTHER | 020025461 | 01 | KY | RAILROAD MEDICARE | OTHER | 64246671 | 05 | KY |   | MEDICAID | 000000062911 | 01 | KY | ANTHEM BCBS | OTHER |