Healthcare Provider Details

I. General information

NPI: 1790983385
Provider Name (Legal Business Name): ST LUKES REGIONAL MEDICAL CENTER DBA ST LUKE'S INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E JEFFERSON ST
BOISE ID
83712-6246
US

IV. Provider business mailing address

PO BOX 550
BOISE ID
83701-0550
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4100
  • Fax: 208-381-4101
Mailing address:
  • Phone: 208-381-4100
  • Fax: 208-381-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

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