Healthcare Provider Details

I. General information

NPI: 1417870882
Provider Name (Legal Business Name): ST LUKES REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 NW 16TH ST STE D
FRUITLAND ID
83619-2272
US

IV. Provider business mailing address

1118 NW 16TH ST STE D
FRUITLAND ID
83619-2272
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-7677
  • Fax:
Mailing address:
  • Phone: 208-452-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACOB PAUL REID
Title or Position: PFS ADMINISTRATION; SR. DIRECTOR
Credential:
Phone: 208-706-7665