Provider Demographics
NPI:1629255153
Name:ST LUKES MEDICAL CENTER WOODRIVER
Entity Type:Organization
Organization Name:ST LUKES MEDICAL CENTER WOODRIVER
Other - Org Name:ST LUKES CLINIC WOODRIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO, VP FINANCE
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 640
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-0640
Mailing Address - Country:US
Mailing Address - Phone:
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:2008-01-28
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62207L00000X, 207R00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID12578911Medicare PIN