Provider Demographics
NPI:1972627628
Name:ST LUKES REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST LUKES REGIONAL MEDICAL CENTER
Other - Org Name:ST LUKES DEVELOPMENTAL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRSCHFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-2818
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:208-381-7312
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:STE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6223
Practice Address - Country:US
Practice Address - Phone:208-381-7312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID032080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID03OtherHOSPITAL STATE LIC #