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DSH130007CJ ST. ALPHONSUS REGIONAL MED CENTER (Terminated)
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Main Details
Name
ST. ALPHONSUS REGIONAL MED CENTER
Subdivision Name
SAMG Sports Medicine MHP
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130007CJ
Medicare Provider Number
130007
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/13/2015
Participating Start Date
4/1/2015
Participating Approval Date
3/11/2015
Last Recertification Date
8/18/2016
Termination Date
Termination Reason
10/1/2016
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
3025 Cherry Lane
Meridian, ID 83642
Billing Address
SAMG Sports Medicine MHP
1055 N. Curtis Rd.
Boise, ID 83706
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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