Basic Information
| Provider Information | |||||||||
| NPI: | 1164454526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERKO | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | AHEARN | ||||||||
| OtherFirstName: | MARILYN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2720 85TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985127511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602509135 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 510 W 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989481564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655600 | ||||||||
| FaxNumber: | 5098655783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD175787 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD00032155 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.