Provider Demographics
NPI:1316034705
Name:BENTZ, MICHAEL EDWARD (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:BENTZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7545 BEECHMONT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4222
Mailing Address - Country:US
Mailing Address - Phone:513-564-4026
Mailing Address - Fax:513-564-4027
Practice Address - Street 1:7545 BEECHMONT AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255
Practice Address - Country:US
Practice Address - Phone:513-564-4027
Practice Address - Fax:513-564-4027
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003075Medicaid
OH0076132Medicaid
S83084Medicare UPIN