Provider Demographics
NPI:1821032376
Name:SAINT ALPHONSUS PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:SAINT ALPHONSUS PHYSICIAN SERVICES INC
Other - Org Name:SAINT ALPHONSUS MEDICAL GROUP TEN MILE
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 1:3250 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1120
Practice Address - Country:US
Practice Address - Phone:208-895-8969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374465Medicare PIN