Provider Demographics
NPI:1508869470
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 WOOD RIVER MEDICAL CENTER
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 1:100 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:208-727-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES HEALTH SYSTEM LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-24
Last Update Date:2022-12-07
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
ID805909800Medicaid
ID805909800Medicaid