Healthcare Provider Details

I. General information

NPI: 1316243330
Provider Name (Legal Business Name): ST LUKE'S REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST STE 200
BOISE ID
83712-6267
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-5000
  • Fax: 208-381-5005
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number03
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number03
License Number StateID

VIII. Authorized Official

Name: JOHN KEE
Title or Position: VP PHYSICIAN SERVICES
Credential:
Phone: 208-381-5329