Provider Demographics
NPI:1164469870
Name:ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTD
Other - Org Name:ST LUKE'S CANYON VIEW BEHAVIORAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-8717
Mailing Address - Street 1:PO BOX 2777
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-2777
Mailing Address - Country:US
Mailing Address - Phone:208-706-5000
Mailing Address - Fax:
Practice Address - Street 1:228 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5022
Practice Address - Country:US
Practice Address - Phone:208-734-6760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES HEALTH SYSTEM LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID100505262OtherNEVADA MEDICAID INPT PROV
ID000010006672OtherBLUE SHIELD 1500 PROV NUM
ID000010006673OtherBLUE SHIELD HOSP PROV #
ID100505262OtherNEVADA MEDICAID INPT PROV
IDCE0659OtherRAILROAD 1500 PROV NUMBER
ID03269OtherBLUE CROSS HOSP PROV #
ID000010006672OtherBLUE SHIELD 1500 PROV NUM
ID8C535OtherBLUE CROSS 1500 PROV NUMB