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DSH130007BN Saint Alphonsus Regional Medical Center (Terminated)
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Main Details
Name
Saint Alphonsus Regional Medical Center
Subdivision Name
SAMG Dallan Woods Family Medicine
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130007BN
Medicare Provider Number
130007
Outpatient Facility Provider Number
130007
Additional Details
Current Program Status
Terminated
Registration Date
7/15/2014
Participating Start Date
10/1/2014
Participating Approval Date
9/3/2014
Last Recertification Date
8/18/2016
Termination Date
Termination Reason
10/1/2017
Site closure
Contacts
Authorizing Official
Saint Alphonsus Health System
Lannie Checketts, RHM CFO Idaho Oregon Region
(208) 367-7347
Primary Contact
Saint Alphonsus Health System
Mark Phillips, AVP Prof Services/Director SAHS Pharmacy
(208) 367-4943
Addresses
Street Address
214 S. Midland Blvd.
Nampa, ID 83686-2602
Billing Address
SAMG Dallan Woods Family Medicine
1055 N. Curtis Rd.
Boise, ID 83706
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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