Provider Demographics
NPI:1801197082
Name:ST LUKE'S REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST LUKE'S REGIONAL MEDICAL CENTER
Other - Org Name:ST LUKE'S CLINIC - IDAHO PEDIATRIC GASTROENTEROLOGY
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:
Authorized Official - Phone:208-381-2520
Mailing Address - Street 1:100 E IDAHO ST
Mailing Address - Street 2:STE 316
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6267
Mailing Address - Country:US
Mailing Address - Phone:208-381-7310
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:STE 316
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-381-7310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKE'S REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID032080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty