Provider Demographics
NPI:1427321934
Name:PORTLAND PAIN AND SPINE LLC
Entity type:Organization
Organization Name:PORTLAND PAIN AND SPINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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 1:9370 SW GREENBURG RD STE 601
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5429
Mailing Address - Country:US
Mailing Address - Phone:503-238-7246
Mailing Address - Fax:503-238-7248
Practice Address - Street 1:9370 SW GREENBURG RD STE 601
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5429
Practice Address - Country:US
Practice Address - Phone:503-238-7246
Practice Address - Fax:503-238-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19519207L00000X, 207LP2900X
208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F96465Medicare UPIN
130869Medicare PIN