Provider Demographics
NPI:1316243330
Name:ST LUKE'S REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:ST LUKE'S REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-5329
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:STE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-381-5000
Practice Address - Fax:208-381-5005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKE'S REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID03103TC2200X, 2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty