Healthcare Provider Details

I. General information

NPI: 1306149919
Provider Name (Legal Business Name): ST LUKE'S REGIONAL MEDICAL CENTER
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

3090 E GENTRY WAY STE 200
MERIDIAN ID
83642-3501
US

IV. Provider business mailing address

2083 E HOSPITALITY LN
BOISE ID
83716-6603
US

V. Phone/Fax

Practice location:
  • Phone: 208-887-6813
  • Fax:
Mailing address:
  • Phone: 208-887-6813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number03
License Number StateID

VIII. Authorized Official

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