Healthcare Provider Details

I. General information

NPI: 1770886384
Provider Name (Legal Business Name): ST LUKE'S MCCALL LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 FOREST ST
MCCALL ID
83638-5256
US

IV. Provider business mailing address

211 FOREST ST
MCCALL ID
83638-5256
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-2225
  • Fax:
Mailing address:
  • Phone: 208-634-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11
License Number StateID

VIII. Authorized Official

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