Provider Demographics
NPI:1063448538
Name:SAINT ALPHONSUS PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:SAINT ALPHONSUS PHYSICIAN SERVICES INC
Other - Org Name:SAINT ALPHONSUS MEDICAL GROUP MCMILLAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:G
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-6490
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:12273 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0555
Practice Address - Country:US
Practice Address - Phone:208-367-6330
Practice Address - Fax:208-367-4765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2007-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374461Medicare PIN