Healthcare Provider Details

I. General information

NPI: 1013957471
Provider Name (Legal Business Name): ST LUKES REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 N CLOVERDALE RD
BOISE ID
83713-2423
US

IV. Provider business mailing address

PO BOX 550
BOISE ID
83701-0550
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-8000
  • Fax: 208-706-8001
Mailing address:
  • Phone: 208-706-8000
  • Fax: 208-706-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARRIE LYNNE COWGILL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 208-381-4137