Provider Demographics
NPI:1083815294
Name:SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
Other - Org Name:SAINT ALPHONSUS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO & BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LANNIE
Authorized Official - Last Name:CHECKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-7347
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-4148
Mailing Address - Fax:208-322-9560
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-367-4148
Practice Address - Fax:208-322-9560
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. ALPHONSUS REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM2363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002267500Medicaid