Healthcare Provider Details

I. General information

NPI: 1790105005
Provider Name (Legal Business Name): MARK FREDERICK BALINO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD SUITE 450
DETROIT MI
48202
US

IV. Provider business mailing address

23151 ARLINGTON ST
DEARBORN MI
48128-1878
US

V. Phone/Fax

Practice location:
  • Phone: 313-871-3751
  • Fax:
Mailing address:
  • Phone: 540-808-6023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101021420
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: