Provider Demographics
NPI:1134296791
Name:BALKOVICH, MICHAEL ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ERIC
Last Name:BALKOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 NE HOYT ST
Mailing Address - Street 2:SUITE 515
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2991
Mailing Address - Country:US
Mailing Address - Phone:503-236-7743
Mailing Address - Fax:503-236-7031
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 515
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-236-7743
Practice Address - Fax:503-236-7031
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD139842086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR221762Medicaid
OR0000BHSXWMedicare ID - Type Unspecified
OR221762Medicaid