Healthcare Provider Details

I. General information

NPI: 1518254481
Provider Name (Legal Business Name): SAMUEL JACKSON BALIN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 12/07/2024
Certification Date: 12/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 BELTLINE RD
SPRINGFIELD OR
97477-1091
US

IV. Provider business mailing address

860 BELTLINE RD
SPRINGFIELD OR
97477-1091
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-4168
  • Fax: 458-201-8510
Mailing address:
  • Phone: 541-344-4168
  • Fax: 458-201-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD197986
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD197986
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: