Healthcare Provider Details

I. General information

NPI: 1568731925
Provider Name (Legal Business Name): ST LUKES REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 E LOUISE DR STE 400
MERIDIAN ID
83642-5047
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-364-3000
  • Fax: 208-364-3191
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number03
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number03
License Number StateID

VIII. Authorized Official

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