Provider Demographics
NPI:1902136823
Name:BERDICHEVSKY, MAX ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:ROBERT
Last Name:BERDICHEVSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BUILDING B, 3RD FLOOR
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:200 MEDICAL CENTER DR STE 375
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005-5180
Practice Address - Country:US
Practice Address - Phone:513-422-8274
Practice Address - Fax:513-217-5762
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60340423207X00000X, 207XS0117X
OH35.132180207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1902136823Medicaid
WA1902136823Medicaid