Basic Information
| Provider Information | |||||||||
| NPI: | 1679663207 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENTZ | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 SUMMITVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989022715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092487849 | ||||||||
| FaxNumber: | 5092488291 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 CREEKSIDE LOOP | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989024882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095751000 | ||||||||
| FaxNumber: | 5092252703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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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 | 207Y00000X | G89294 | CA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 60914678 | WA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | HA874Z | 01 | CA | PTAN FOR RIDEOUT MEDICAL ASSOCIATES, INC. | OTHER |