Basic Information
| Provider Information | |||||||||
| NPI: | 1962556787 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORALYN ALEXANDER MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2103 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833032103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087343900 | ||||||||
| FaxNumber: | 2087339463 | ||||||||
| Practice Location | |||||||||
| Address1: | 488 BLUE LAKES BLVD N | ||||||||
| Address2: | STE 102 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833014800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087343900 | ||||||||
| FaxNumber: | 2087339463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | ALEXANDER | ||||||||
| AuthorizedOfficialFirstName: | CORALYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087343900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | M6940 | ID | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 808649500 | 05 | ID | MEDICAID |