Provider Demographics
NPI:1114117611
Name:ST LUKES REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST LUKES REGIONAL MEDICAL CENTER
Other - Org Name:ST LUKES BARIATRIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:OAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-344-3779
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-0550
Mailing Address - Country:US
Mailing Address - Phone:208-344-3779
Mailing Address - Fax:
Practice Address - Street 1:333 N 1ST ST
Practice Address - Street 2:SUITE 120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6100
Practice Address - Country:US
Practice Address - Phone:208-344-3779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4219261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B63464Medicare UPIN
1250906Medicare PIN