Provider Demographics
NPI:1114915147
Name:VAN DEN BERG-WOLF, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:VAN DEN BERG-WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SW 146TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1912
Mailing Address - Country:US
Mailing Address - Phone:206-630-3000
Mailing Address - Fax:206-630-3001
Practice Address - Street 1:225 E CITY AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1704
Practice Address - Country:US
Practice Address - Phone:215-503-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60806378207R00000X
PAMD025054E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014457420001Medicaid
748422Medicare ID - Type Unspecified
PA0014457420001Medicaid