Provider Demographics
NPI:1265671739
Name:ST LUKE'S MEDICAL CENTER WOOD RIVER LTD
Entity Type:Organization
Organization Name:ST LUKE'S MEDICAL CENTER WOOD RIVER LTD
Other - Org Name:ST LUKES CLINIC WOODRIVER - ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP FINANCE, 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: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:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-788-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID12578912Medicare PIN