Healthcare Provider Details

I. General information

NPI: 1316987803
Provider Name (Legal Business Name): ANTHONY BEAUMONT VAN BERGEYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 5TH ST SE STE 110
PUYALLUP WA
98374-2106
US

IV. Provider business mailing address

3801 5TH ST SE STE 110
PUYALLUP WA
98374-2106
US

V. Phone/Fax

Practice location:
  • Phone: 253-845-9585
  • Fax: 253-848-1126
Mailing address:
  • Phone: 253-845-9585
  • Fax: 253-848-1126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number601484763
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberMD00044729
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: