Healthcare Provider Details

I. General information

NPI: 1619243276
Provider Name (Legal Business Name): PEND OREILLE RADIOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N THIRD AVE
SANDPOINT ID
83864-1507
US

IV. Provider business mailing address

PO BOX 2228
COEUR D ALENE ID
83816
US

V. Phone/Fax

Practice location:
  • Phone: 559-455-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES W MAILE
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 208-263-1441