1134296791 NPI number — DR. MICHAEL ERIC BALKOVICH MD

Table of content: DR. MICHAEL ERIC BALKOVICH MD (NPI 1134296791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134296791 NPI number — DR. MICHAEL ERIC BALKOVICH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALKOVICH
Provider First Name:
MICHAEL
Provider Middle Name:
ERIC
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134296791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 NE HOYT ST
Provider Second Line Business Mailing Address:
SUITE 515
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97213-2991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-236-7743
Provider Business Mailing Address Fax Number:
503-236-7031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 NE HOYT ST
Provider Second Line Business Practice Location Address:
SUITE 515
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-2991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-236-7743
Provider Business Practice Location Address Fax Number:
503-236-7031
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  MD13984 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 221762 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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