Basic Information
| Provider Information | |||||||||
| NPI: | 1568717544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN DEN BERGH | ||||||||
| FirstName: | MAGALI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8260 GLADIOLUS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394375755 | ||||||||
| FaxNumber: | 2394375776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | ME136601 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RX0202X | ME136601 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 025121700 | 05 | FL | MEDICAID |