Healthcare Provider Details

I. General information

NPI: 1801197082
Provider Name (Legal Business Name): ST LUKE'S REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST STE 316
BOISE ID
83712-6267
US

IV. Provider business mailing address

100 E IDAHO ST STE 316
BOISE ID
83712-6267
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7310
  • Fax:
Mailing address:
  • Phone: 208-381-7310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number03
License Number StateID

VIII. Authorized Official

Name: JEFF TAYLOR
Title or Position: SYSTEM VP CFO
Credential:
Phone: 208-381-2520