=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124941588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST LUKE'S REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2026
-----------------------------------------------------
Last Update Date | 08/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E IDAHO ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83712-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-2711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E IDAHO ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83712-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-2711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PFS ADMINISTRATION; SR. DIRECTOR
-----------------------------------------------------
Name | JACOB PAUL REID
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-706-7665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0203X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------