Provider Demographics
NPI:1790983385
Name:ST LUKES REGIONAL MEDICAL CENTER DBA ST LUKE'S INTERNAL MEDICINE
Entity Type:Organization
Organization Name:ST LUKES REGIONAL MEDICAL CENTER DBA ST LUKE'S INTERNAL MEDICINE
Other - Org Name:SLIM MIDLEVEL PROVIDERS
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:COWGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-4137
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-0550
Mailing Address - Country:US
Mailing Address - Phone:208-381-4100
Mailing Address - Fax:208-381-4101
Practice Address - Street 1:300 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6246
Practice Address - Country:US
Practice Address - Phone:208-381-4100
Practice Address - Fax:208-381-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty