MEDICARE: MR. PHILIP A VANDE BERG M.S., A.T.C.

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	2255A2300X	Athletic Trainer	RT-003104	PA

General Provider Information

NPI Number	:	1609832112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILIP A VANDE BERG M.S., A.T.C.

Provider Business Mailing Address
First Line	:	3141 CHESTNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2816
Country	:	US
Telephone Number	:	215-895-0497
Fax Number	:	215-895-1943

Provider Business Practice Location Address
First Line	:	3141 CHESTNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2816
Country	:	US
Telephone Number	:	215-895-0497
Fax Number	:	215-895-1943

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

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	07/08/2007

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