Provider Demographics
NPI:1932154705
Name:ST. LUKE'S MAGIC VALLEY REGIONAL MEDICAL CENTER, LTD.
Entity Type:Organization
Organization Name:ST. LUKE'S MAGIC VALLEY REGIONAL MEDICAL CENTER, LTD.
Other - Org Name:ST LUKES MAGIC VALLEY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-8717
Mailing Address - Street 1:PO BOX 2777
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-2777
Mailing Address - Country:US
Mailing Address - Phone:208-706-5000
Mailing Address - Fax:
Practice Address - Street 1:801 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5810
Practice Address - Country:US
Practice Address - Phone:208-814-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES HEALTH SYSTEM LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID14282N00000X, 282N00000X
ID341600000X
3416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No341600000XTransportation ServicesAmbulance
No3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807496600Medicaid
ID807496600Medicaid
ID00018OtherBLUE CROSS OF IDAHO
ID00018OtherBLUE CROSS OF IDAHO
ID000010006647OtherREGENCE BLUE SHIELD OF ID