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DSH130007G Saint Alphonsus Regional Medical Center (Terminated)
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Main Details
Name
Saint Alphonsus Regional Medical Center
Subdivision Name
SAMG Shoreline Family Medicine
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130007G
Medicare Provider Number
130007
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/15/2013
Participating Start Date
4/1/2013
Participating Approval Date
3/28/2013
Last Recertification Date
8/13/2014
Termination Date
Termination Reason
10/1/2015
Site closure
Contacts
Authorizing Official
Saint Alphonsus Health System
Lannie Checketts, RHM CFO Idaho Oregon Region
(208) 367-7347
Primary Contact
Mark Phillips, Director of Pharmacy
(208) 367-4943
Addresses
Street Address
1673 W. Shoreline Dr., Ste. 120
Boise, ID 83702-6749
Billing Address
SAMG Shoreline Family Medicine
1055 N. Curtis Rd.
Boise, ID 83706
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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