Provider Demographics
NPI:1275662546
Name:ST LUKES WOOD RIVER MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:ST LUKES WOOD RIVER MEDICAL CENTER LTD
Other - Org Name:ST LUKES WOODRIVER SWINGBEDS
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:208-381-2333
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-9998
Practice Address - Country:US
Practice Address - Phone:208-788-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES HEALTH SYSTEM LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-05
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID62OtherSTATE LIC #
ID13Z323Medicare Oscar/Certification
ID62OtherSTATE LIC #