Healthcare Provider Details

I. General information

NPI: 1841291861
Provider Name (Legal Business Name): CHARLES W MAILE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 NORTH THIRD
SANDPOINT ID
83864-1507
US

IV. Provider business mailing address

PO BOX 1448
SANDPOINT ID
83864-0877
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1441
  • Fax: 208-265-1278
Mailing address:
  • Phone: 208-263-1441
  • Fax: 208-265-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number25618
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number25618
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25618
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM9573
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: