MEDICARE: ST LUKE'S REGIONAL MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	03	ID
2	207X00000X	Orthopaedic Surgery Physician	03	ID

General Provider Information

NPI Number	:	1821314584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST LUKE'S REGIONAL MEDICAL CENTER

Provider Business Mailing Address
First Line	:	190 E BANNOCK ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83712-6241
Country	:	US
Telephone Number	:	208-287-9605
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 S EAGLE RD
Second Line	:	SUITE 3213
City	:	MERIDIAN
State	:	ID
Zip	:	83642-6351
Country	:	US
Telephone Number	:	208-287-9605
Fax Number	:

Authorized Official
Title or Position	:	VP PHYSICIAN SERVICES
Name	:	JOHN KEE
Credential	:
Telephone Number	:	208-381-5329

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	04/20/2010

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