Provider Demographics
NPI:1568731925
Name:ST LUKES REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST LUKES REGIONAL MEDICAL CENTER
Other - Org Name:ST LUKES CLINIC - GENERAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEM VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:208-381-2520
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:3399 E LOUISE DR
Practice Address - Street 2:STE 400
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5047
Practice Address - Country:US
Practice Address - Phone:208-364-3000
Practice Address - Fax:208-364-3191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID03208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty