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General NPI Number Information
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NPI Number | 1720204738
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Entity Type | Organization
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Legal Business Name | ST LUKES REGIONAL MED CTR DBA ST LUKES PEDIATRIC SURGERY OF IDAHO
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 04/09/2008
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Provider Practice Location Address
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Address Line | 100 E IDAHO ST SUITE 300
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City | BOISE
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State | ID
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Zip | 83712-6223
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Country | US
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Telephone | 208-345-5400
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Fax | 208-345-5454
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Provider Business Mailing Address
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Address Line | 100 E IDAHO ST SUITE 300
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City | BOISE
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State | ID
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Zip | 83712-6223
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Country | US
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Telephone | 208-345-5400
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Fax | 208-345-5454
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | MS. CARRIE L COWGILL
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Credential |
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Telephone | 208-381-4137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0120X
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Taxonomy Name | Pediatric Surgery Physician
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License Number |
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License Number State |
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