Provider Demographics
NPI:1700053774
Name:ST BENEDICTS FMC PHYSICIAN ASSISTANTS
Entity Type:Organization
Organization Name:ST BENEDICTS FMC PHYSICIAN ASSISTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-324-1122
Mailing Address - Street 1:709 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-1851
Mailing Address - Country:US
Mailing Address - Phone:208-324-4301
Mailing Address - Fax:208-324-9529
Practice Address - Street 1:709 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1851
Practice Address - Country:US
Practice Address - Phone:208-324-4301
Practice Address - Fax:208-324-9529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST BENEDICTS FAMILY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID08363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty