Provider Demographics
NPI:1528265790
Name:CHAILLE, MATILDE N (MD)
Entity type:Individual
Prefix:
First Name:MATILDE
Middle Name:N
Last Name:CHAILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MATILDE
Other - Middle Name:
Other - Last Name:NUMENZC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6807
Mailing Address - Country:US
Mailing Address - Phone:803-335-1219
Mailing Address - Fax:803-335-1689
Practice Address - Street 1:410 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 2300
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6807
Practice Address - Country:US
Practice Address - Phone:803-335-1219
Practice Address - Fax:803-335-1689
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0092022084P0800X
SC92022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC092027Medicaid
SCSC4580D896Medicare PIN
GAD05691Medicare PIN
D05691Medicare UPIN