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: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4730
  • Fax: 517-205-4701
Mailing address:
  • Phone: 800-999-5829
  • Fax: 313-876-1305

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: