1073559449 NPI number — SAINT ALPHONSUS PHYSICIAN SERVICES INC

Table of content: (NPI 1073559449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073559449 NPI number — SAINT ALPHONSUS PHYSICIAN SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAINT ALPHONSUS PHYSICIAN SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073559449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 E GOLDSTONE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-5170
Provider Business Mailing Address Fax Number:
208-367-5180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1673 SHORELINE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-6749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-429-8311
Provider Business Practice Location Address Fax Number:
208-429-8310
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REILLY
Authorized Official First Name:
JANELLE
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-367-6490

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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