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DSH130007DA ST. ALPHONSUS REGIONAL MED CENTER (Terminated)
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Main Details
Name
ST. ALPHONSUS REGIONAL MED CENTER
Subdivision Name
SAMG Clinic At Eagle
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH130007DA
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
10/1/2017
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
600 E State St Ste 200
Eagle, ID 83616
Billing Address
SAMG Clinic At Eagle
1055 N. Curtis Rd.
Boise, ID 83706
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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