=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831275684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLEN J. BENTLEY, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 MOUNT HOPE AVE SUITE 430
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-5691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-945-4300
-----------------------------------------------------
Fax | 207-945-0755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 MOUNT HOPE AVE SUITE 430
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-5691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-945-4300
-----------------------------------------------------
Fax | 207-945-0755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELLEN J BENTLEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 207-945-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 013186
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------