Provider Demographics
NPI:1629116561
Name:SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
Other - Org Name:SAINT ALPHONSUS BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
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 MED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-02
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 1041C0700X, 2084P0800X, 2084P0804X
ID363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1250802Medicare Oscar/Certification
ID1691782Medicare Oscar/Certification