Provider Demographics
NPI:1154393437
Name:BENTLEY, FELICIA R (MD)
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:R
Last Name:BENTLEY
Suffix:
Gender:F
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:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0449
Mailing Address - Country:US
Mailing Address - Phone:314-438-0700
Mailing Address - Fax:
Practice Address - Street 1:247 DUNN RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7928
Practice Address - Country:US
Practice Address - Phone:314-438-0700
Practice Address - Fax:314-438-0737
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107319207RN0300X
MO2002015961207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205933203Medicaid
MO205933203Medicaid
H42655Medicare UPIN