Provider Demographics
| NPI: | 1013136209 |
|---|---|
| Name: | SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC |
| Entity type: | Organization |
| Organization Name: | SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| 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: | 208-367-2844 |
| Mailing Address - Street 1: | 901 N CURTIS RD |
| Mailing Address - Street 2: | #204 |
| Mailing Address - City: | BOISE |
| Mailing Address - State: | ID |
| Mailing Address - Zip Code: | 83706-1338 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 208-367-8950 |
| Mailing Address - Fax: | 208-367-6908 |
| Practice Address - Street 1: | 179 SW 5TH AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | MERIDIAN |
| Practice Address - State: | ID |
| Practice Address - Zip Code: | 83642-2995 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 208-367-8282 |
| Practice Address - Fax: | 208-367-8288 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2007-04-25 |
| Last Update Date: | 2024-10-17 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 2251P0200X, 225XP0200X | ||
| ID | 2 | 1041C0700X, 111NR0400X, 225800000X, 225X00000X, 2278P1005X, 235Z00000X, 225100000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 111NR0400X | Chiropractic Providers | Chiropractor | Rehabilitation | Group - Multi-Specialty |
| No | 225800000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | Group - Multi-Specialty |
| No | 2278P1005X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Certified | Pulmonary Rehabilitation | Group - Multi-Specialty |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| ID | 002265701 | Medicaid | |
| ID | 136539 | Medicare PIN |
