Healthcare Provider Details

I. General information

NPI: 1467494211
Provider Name (Legal Business Name): MARSHALL JOHN BALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SOUTH DRIVE
WINNEBAGO WI
54985-0009
US

IV. Provider business mailing address

601 HOUGHTELING ST
IRON MOUNTAIN MI
49801-6828
US

V. Phone/Fax

Practice location:
  • Phone: 920-235-4910
  • Fax: 920-237-2043
Mailing address:
  • Phone: 906-396-5075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number31871
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number04-23919
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: