Provider Demographics
NPI:1952348641
Name:ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-737-2101
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0409
Mailing Address - Country:US
Mailing Address - Phone:208-814-7459
Mailing Address - Fax:208-814-7459
Practice Address - Street 1:801 POLELINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5799
Practice Address - Country:US
Practice Address - Phone:208-814-7459
Practice Address - Fax:208-814-7491
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID02576OtherBLUE CROSS PROV NUMBER
ID135118Medicare ID - Type UnspecifiedMEDICARE HOSP PROV NUMBER