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DSH130007BU Saint Alphonsus Regional Medical Center (Terminated)
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Main Details
Name
Saint Alphonsus Regional Medical Center
Subdivision Name
SAMG Coughlin Clinic Dallan Woods
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130007BU
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
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
Kenneth Fry, VP Finance
(208) 367-3445
Addresses
Street Address
214 S. Midland Blvd.
Nampa, ID 83686-2602
Billing Address
SAMG Coughlin Clinic Dallan Woods
1055 N. Curtis Rd.
Boise, ID 83706
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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