Healthcare Provider Details

I. General information

NPI: 1780793596
Provider Name (Legal Business Name): ST LUKE'S REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD STE 3112
MERIDIAN ID
83642-6351
US

IV. Provider business mailing address

PO BOX 640
BOISE ID
83701-0640
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-5800
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number03
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number03
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number03
License Number StateID

VIII. Authorized Official

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