Basic Information
| Provider Information | |||||||||
| NPI: | 1619243276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEND OREILLE RADIOLOGY INC | ||||||||
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| Address1: | PO BOX 2228 | ||||||||
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| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83816 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 N THIRD AVE | ||||||||
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| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554000 | ||||||||
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| ProviderEnumerationDate: | 03/28/2012 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | MAILE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2082631441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.