MEDICARE: DR. MARY VAN DEN BERG-WOLF MD

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	207R00000X	Internal Medicine Physician	MD60806378	WA
2	207R00000X	Internal Medicine Physician	MD025054E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114915147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY VAN DEN BERG-WOLF MD

Provider Business Mailing Address
First Line	:	140 SW 146TH ST
Second Line	:
City	:	BURIEN
State	:	WA
Zip	:	98166-1912
Country	:	US
Telephone Number	:	206-630-3000
Fax Number	:	206-630-3001

Provider Business Practice Location Address
First Line	:	225 E CITY AVE
Second Line	:	SUITE 109
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1704
Country	:	US
Telephone Number	:	215-503-3838
Fax Number	:

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

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	07/30/2018

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