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General NPI Number Information
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NPI Number | 1134375421
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Entity Type | Organization
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Legal Business Name | SILVER FALLS DERMATOLOGY, LLC
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Dates
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Enumeration Date | 08/18/2008
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 1793 13TH ST SE
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City | SALEM
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State | OR
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Zip | 97302-2541
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Country | US
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Telephone | 503-362-8385
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Fax | 503-362-8435
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Provider Business Mailing Address
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Address Line | 1793 13TH ST SE
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City | SALEM
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State | OR
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Zip | 97302-2541
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Country | US
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Telephone | 503-362-8385
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Fax | 503-362-8435
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | MALISSA KOBBEVIK
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Credential |
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Telephone | 360-375-2038
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | MD26178
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207NI0002X
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Taxonomy Name | Clinical & Laboratory Dermatological Immunology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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