=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578763355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAX WAYNE BERRY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2007
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3650 PIPER STREET, STE A
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-339-9455
-----------------------------------------------------
Fax | 907-339-9445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3650 PIPER STREET, STE A
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-339-9455
-----------------------------------------------------
Fax | 907-339-9445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | MD60343987
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 30970
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 31693
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | Q9958
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------