1720079387 NPI number — SAINT ALPHONSUS NEPHROLOGY

Table of content: (NPI 1720079387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720079387 NPI number — SAINT ALPHONSUS NEPHROLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAINT ALPHONSUS NEPHROLOGY
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:
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:
1720079387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5610 GAGE ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83706-1349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-3076
Provider Business Mailing Address Fax Number:
208-367-6909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2303 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-677-5490
Provider Business Practice Location Address Fax Number:
208-677-5498
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
JAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ACCOUNTS RECEIVABLE MANAGER
Authorized Official Telephone Number:
208-367-3076

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  BM5584708 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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