Provider Demographics
NPI:1457391849
Name:ST LUKES HEALTH RESOURCES
Entity type:Organization
Organization Name:ST LUKES HEALTH RESOURCES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-279-3934
Mailing Address - Street 1:2720 STONE PARK BLVD
Mailing Address - Street 2:ROOM 629
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3734
Mailing Address - Country:US
Mailing Address - Phone:712-279-3380
Mailing Address - Fax:712-279-7015
Practice Address - Street 1:2730 PIERCE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3796
Practice Address - Country:US
Practice Address - Phone:712-277-2030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0276311Medicaid
470000727OtherRR MEDICARE
470000727OtherRR MEDICARE