=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639356173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST LUKES REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2008
-----------------------------------------------------
Last Update Date | 01/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11311 W CHINDEN BLVD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83714-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-4120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 550
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83701-0550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-4120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | SHANNA RICHTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-381-4120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 03
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------