MEDICARE: ST LUKES CLINIC-TREASURE VALLEY LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207Q00000X	Family Medicine Physician	ID
2	207R00000X	Internal Medicine Physician	ID
3	208000000X	Pediatrics Physician	ID
4	261QR1300X	Rural Health Clinic/Center	ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1369110	OTHER	ID	MEDICARE / MULTI SPECIALTY CLINIC
2	133999	OTHER	ID	MEDICARE / RHC

General Provider Information

NPI Number	:	1417297821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST LUKES CLINIC-TREASURE VALLEY LLC

Provider Business Mailing Address
First Line	:	PO BOX 640
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83701-0640
Country	:	US
Telephone Number	:	208-381-2222
Fax Number	:

Provider Business Practice Location Address
First Line	:	465 MCKENNA DR
Second Line	:
City	:	MOUNTAIN HOME
State	:	ID
Zip	:	83647-2143
Country	:	US
Telephone Number	:	208-587-9703
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VP, CFO
Name	:	KATHRYN FOWLER
Credential	:
Telephone Number	:	208-381-8717

Provider Enumeration Date	:	02/21/2013
Last Update Date	:	12/08/2022

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Directions to “ST LUKES CLINIC-TREASURE VALLEY LLC ” Practice Location

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