Healthcare Provider Details

I. General information

NPI: 1508869470
Provider Name (Legal Business Name): ST LUKES WOOD RIVER MEDICAL CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DR
KETCHUM ID
83340-9998
US

IV. Provider business mailing address

PO BOX 2777
BOISE ID
83701-2777
US

V. Phone/Fax

Practice location:
  • Phone: 208-727-8100
  • Fax:
Mailing address:
  • Phone: 208-706-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number62
License Number StateID

VIII. Authorized Official

Name: KATHRYN FOWLER
Title or Position: SENIOR VP, CFO
Credential:
Phone: 208-381-8717