Healthcare Provider Details

I. General information

NPI: 1720204738
Provider Name (Legal Business Name): ST LUKES REGIONAL MED CTR DBA ST LUKES PEDIATRIC SURGERY OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST SUITE 300
BOISE ID
83712-6223
US

IV. Provider business mailing address

100 E IDAHO ST SUITE 300
BOISE ID
83712-6223
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-5400
  • Fax: 208-345-5454
Mailing address:
  • Phone: 208-345-5400
  • Fax: 208-345-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CARRIE L COWGILL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 208-381-4137