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NPI Code Detail

MEDICARE: SAINT ALPHONSUS NEPHROLOGY

MEDICARE: SAINT ALPHONSUS NEPHROLOGY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QE0700XEnd-Stage Renal Disease (ESRD) Treatment Clinic/CenterBM5584708ID

General Provider Information

NPI Number : 1720079387
Entity Type Code : Organization
Provider Name (Legal Business Name) : SAINT ALPHONSUS NEPHROLOGY
Provider Business Mailing Address
First Line : 5610 GAGE ST
Second Line : SUITE B
City : BOISE
State : ID
Zip : 83706-1349
Country : US
Telephone Number : 208-367-3076
Fax Number : 208-367-6909
Provider Business Practice Location Address
First Line : 2303 PARK AVE
Second Line :
City : BURLEY
State : ID
Zip : 83318-2106
Country : US
Telephone Number : 208-677-5490
Fax Number : 208-677-5498
Authorized Official
Title or Position : ACCOUNTS RECEIVABLE MANAGER
Name : JAN M JACOBS
Credential :
Telephone Number : 208-367-3076
Provider Enumeration Date : 11/02/2005
Last Update Date : 08/22/2020

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