Provider Demographics
NPI:1770873572
Name:ST LUKES IDAHO CARDIOLOGY ASSOCIATES
Entity type:Organization
Organization Name:ST LUKES IDAHO CARDIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-963-1454
Mailing Address - Street 1:900 SUNSET DR
Mailing Address - Street 2:PO BOX 3290
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1362
Mailing Address - Country:US
Mailing Address - Phone:541-963-1555
Mailing Address - Fax:541-963-1845
Practice Address - Street 1:315 E ELM ST
Practice Address - Street 2:SUITE 350
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4857
Practice Address - Country:US
Practice Address - Phone:208-454-6363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANDE RONDE HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR140728207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1368978Medicare UPIN