Healthcare Provider Details

I. General information

NPI: 1508834219
Provider Name (Legal Business Name): MARY T BERNARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER FORT LEWIS
TACOMA WA
98431-0001
US

IV. Provider business mailing address

2306 37TH AVE SE
PUYALLUP WA
98374-1967
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1975
  • Fax:
Mailing address:
  • Phone: 253-777-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD00041798
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: