Provider Demographics
NPI:1366874877
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:<UNAVAIL>
Other - Org Type:
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:208-324-4301
Mailing Address - Fax:
Practice Address - Street 1:709 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1851
Practice Address - Country:US
Practice Address - Phone:208-324-4301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES HEALTH SYSTEM LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-07
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID08282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002287000Medicaid
ID002287000Medicaid
ID00265OtherBLUE CROSS OF IDAHO
ID000010006683OtherBLUE SHIELD OF IDAHO
ID002287000Medicaid
ID131310Medicare Oscar/Certification
ID131310Medicare PIN