MEDICARE: DR. SHANNON K BENTLEY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35.075269	OH
2	207Q00000X	Family Medicine Physician	22184	WV
3	207VX0000X	Obstetrics Physician	49699	KY
4	207Q00000X	Family Medicine Physician	49699	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	K228150	OTHER	KY	KY MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033179817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON K BENTLEY M.D.

Provider Business Mailing Address
First Line	:	413 S LOOP RD
Second Line	:	ST ELIZABETH FAMILY PRACTICE CENTER
City	:	EDGEWOOD
State	:	KY
Zip	:	41017-5446
Country	:	US
Telephone Number	:	859-301-3800
Fax Number	:	859-301-3987

Provider Business Practice Location Address
First Line	:	413 SOUTH LOOP ROAD
Second Line	:	ST ELIZABETH FAMILY PRACTICE CENTER
City	:	EDGEWOOD
State	:	KY
Zip	:	41017-5446
Country	:	US
Telephone Number	:	859-301-3800
Fax Number	:	859-301-3987

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	08/10/2022

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