Provider Demographics
NPI:1922282821
Name:CORALYN J ALEXANDER MD PA
Entity Type:Organization
Organization Name:CORALYN J ALEXANDER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-734-3900
Mailing Address - Street 1:PO BOX 2103
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-2103
Mailing Address - Country:US
Mailing Address - Phone:208-734-3900
Mailing Address - Fax:208-734-9441
Practice Address - Street 1:488 BLUE LAKES BLVD N
Practice Address - Street 2:STE 102
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4800
Practice Address - Country:US
Practice Address - Phone:208-734-3900
Practice Address - Fax:208-734-9441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP662261QM0850X
IDM6940261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804052700Medicaid