Provider Demographics
NPI:1871883868
Name:CORVALLIS PAIN AND SPINE INC
Entity type:Organization
Organization Name:CORVALLIS PAIN AND SPINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BALOG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-887-2209
Mailing Address - Street 1:2364 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9361
Mailing Address - Country:US
Mailing Address - Phone:541-929-2040
Mailing Address - Fax:541-929-2170
Practice Address - Street 1:2364 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370-9361
Practice Address - Country:US
Practice Address - Phone:541-929-2040
Practice Address - Fax:541-929-2170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR831633001OtherBCBS
OR74062Medicaid
OR74062Medicaid