Provider Demographics
NPI:1124020268
Name:VON BERGEN, HAROLD GEORGE (PT)
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:GEORGE
Last Name:VON BERGEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16431 PUTTER CIR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-3802
Mailing Address - Country:US
Mailing Address - Phone:360-757-0746
Mailing Address - Fax:
Practice Address - Street 1:210 FERRY ST
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-1411
Practice Address - Country:US
Practice Address - Phone:360-856-4216
Practice Address - Fax:360-856-4217
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000529208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA31210OtherSTATE INDUSTRIAL
WA70040-05Medicaid
WA31210OtherSTATE INDUSTRIAL
WAAB20472Medicare ID - Type Unspecified