Provider Demographics
| NPI: | 1649357716 |
|---|---|
| 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 |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | BRIAN |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | CHECKETTS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 208-367-7347 |
| Mailing Address - Street 1: | 1055 N CURTIS RD |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BOISE |
| Mailing Address - State: | ID |
| Mailing Address - Zip Code: | 83706-1309 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 208-367-4148 |
| Mailing Address - Fax: | |
| 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: | SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-11-01 |
| Last Update Date: | 2023-01-24 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| ID | 2 | 103G00000X, 1041C0700X, 207RC0000X, 207RP1001X, 207T00000X, 207XX0801X, 2084N0400X, 2086S0127X, 363A00000X, 363L00000X, 103T00000X |
| ID | M2 | 207LH0002X |
| 207ZP0102X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 207LH0002X | Allopathic & Osteopathic Physicians | Anesthesiology | Hospice and Palliative Medicine | Group - Multi-Specialty |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207XX0801X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | Group - Multi-Specialty |
| No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 2086S0127X | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| ID | 002266100 | Medicaid | |
| ID | 002267500 | Medicaid | |
| ID | 805068500 | Medicaid | |
| ID | 1250802 | Medicare Oscar/Certification |
