MEDICARE: SILVER FALLS DERMATOLOGY, LLC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	MD26178	OR
2	207ND0101X	MOHS-Micrographic Surgery Physician
3	207ND0900X	Dermatopathology Physician
4	207NI0002X	Clinical & Laboratory Dermatological Immunology Physician
5	207NS0135X	Procedural Dermatology Physician
6	363A00000X	Physician Assistant
7	363L00000X	Nurse Practitioner
8	207N00000X	Dermatology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1134375421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SILVER FALLS DERMATOLOGY, LLC

Provider Business Mailing Address
First Line	:	1793 13TH ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-2541
Country	:	US
Telephone Number	:	503-362-8385
Fax Number	:	503-362-8435

Provider Business Practice Location Address
First Line	:	1793 13TH ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-2541
Country	:	US
Telephone Number	:	503-362-8385
Fax Number	:	503-362-8435

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MALISSA KOBBEVIK
Credential	:
Telephone Number	:	360-375-2038

Provider Enumeration Date	:	08/18/2008
Last Update Date	:	10/17/2024