Provider Demographics
NPI:1619147691
Name:BERTHOLF, MAX ERWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:ERWIN
Last Name:BERTHOLF
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:200 THE GLEBE BLVD
Mailing Address - Street 2:#3010
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083-3726
Mailing Address - Country:US
Mailing Address - Phone:540-591-2333
Mailing Address - Fax:540-591-2333
Practice Address - Street 1:498 COYNER SPRINGS RD
Practice Address - Street 2:ROANOKE VALLEY JUVENILE DETENTION CENTER, MED. DIRECTOR
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-9038
Practice Address - Country:US
Practice Address - Phone:540-561-3840
Practice Address - Fax:540-561-3848
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101012335208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VABO7559Medicaid