Healthcare Provider Details

I. General information

NPI: 1821314584
Provider Name (Legal Business Name): ST LUKE'S REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD SUITE 3213
MERIDIAN ID
83642-6351
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-287-9605
  • Fax:
Mailing address:
  • Phone: 208-287-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number03
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number03
License Number StateID

VIII. Authorized Official

Name: JOHN KEE
Title or Position: VP PHYSICIAN SERVICES
Credential:
Phone: 208-381-5329