Provider Demographics
NPI:1720204738
Name:ST LUKES REGIONAL MED CTR DBA ST LUKES PEDIATRIC SURGERY OF IDAHO
Entity Type:Organization
Organization Name:ST LUKES REGIONAL MED CTR DBA ST LUKES PEDIATRIC SURGERY OF IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COWGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-4137
Mailing Address - Street 1:100 E IDAHO ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6223
Mailing Address - Country:US
Mailing Address - Phone:208-345-5400
Mailing Address - Fax:208-345-5454
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6223
Practice Address - Country:US
Practice Address - Phone:208-345-5400
Practice Address - Fax:208-345-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12509031Medicare PIN