Provider Demographics
NPI:1669482139
Name:BENTLEY, RYAN E (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:E
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 OAKLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 136TH AVE STE 416
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2905
Practice Address - Country:US
Practice Address - Phone:616-294-3211
Practice Address - Fax:714-362-9011
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301500471207Q00000X
IN08002056111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
INBE825Medicare UPIN