Provider Demographics
NPI:1003295452
Name:ST LUKES REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST LUKES REGIONAL MEDICAL CENTER
Other - Org Name:ST LUKE'S HUMPHREYS DIABETES CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-2520
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:1226 W RIVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7049
Practice Address - Country:US
Practice Address - Phone:208-331-1155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID03133V00000X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1003295452Medicaid
ID20007319Medicare PIN