Healthcare Provider Details

I. General information

NPI: 1386677524
Provider Name (Legal Business Name): ST ALPHONSUS PROFESSIONAL MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

Provider Other Name: SAMG ANESTHESIA

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax: 208-367-2742
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN CHECKETTS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 208-367-7347