Basic Information
| Provider Information | |||||||||
| NPI: | 1184606774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTZ | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | DUANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7675 MADISON ST NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637854500 | ||||||||
| FaxNumber: | 7637853314 | ||||||||
| Practice Location | |||||||||
| Address1: | 7675 MADISON ST NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637854500 | ||||||||
| FaxNumber: | 7637853314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32373 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07782310C | 05 | MN | MEDICAID |