Healthcare Provider Details

I. General information

NPI: 1164454526
Provider Name (Legal Business Name): MARILYN BERKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARILYN AHEARN MD

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W 1ST AVE
TOPPENISH WA
98948-1564
US

IV. Provider business mailing address

2720 85TH AVE SW
TUMWATER WA
98512-7511
US

V. Phone/Fax

Practice location:
  • Phone: 509-865-5600
  • Fax: 509-865-5783
Mailing address:
  • Phone: 360-250-9135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD175787
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00032155
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: