Healthcare Provider Details

I. General information

NPI: 1659699841
Provider Name (Legal Business Name): ST LUKE'S REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 1ST ST STE 280
BOISE ID
83702-6100
US

IV. Provider business mailing address

PO BOX 640
BOISE ID
83701-0640
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-6545
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number03
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number03
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number03
License Number StateID

VIII. Authorized Official

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