Provider Demographics
NPI:1720079387
Name:SAINT ALPHONSUS NEPHROLOGY
Entity Type:Organization
Organization Name:SAINT ALPHONSUS NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-3076
Mailing Address - Street 1:5610 GAGE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1349
Mailing Address - Country:US
Mailing Address - Phone:208-367-3076
Mailing Address - Fax:208-367-6909
Practice Address - Street 1:2303 PARK AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2106
Practice Address - Country:US
Practice Address - Phone:208-677-5490
Practice Address - Fax:208-677-5498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDBM5584708261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID132503Medicare ID - Type Unspecified