=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306137633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST LUKES IDAHO CARDIOLOGY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2011
-----------------------------------------------------
Last Update Date | 04/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 E HAWAII AVE
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-6011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-322-1680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 SUNSET DR PO BOX 3290
-----------------------------------------------------
City | LA GRANDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97850-1362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-963-1555
-----------------------------------------------------
Fax | 541-963-1845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. JAMES A MATTES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 541-963-1454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 140728
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------