Provider Demographics
NPI:1316980345
Name:ST LUKES REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:ST LUKES REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:COWGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-4137
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:208-706-5100
Mailing Address - Fax:208-706-5169
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 3102
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-706-5100
Practice Address - Fax:208-706-5169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1250904Medicare ID - Type Unspecified