Basic Information
| Provider Information | |||||||||
| NPI: | 1013957471 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST LUKES REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ST LUKES INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837010550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087068000 | ||||||||
| FaxNumber: | 2087068001 | ||||||||
| Practice Location | |||||||||
| Address1: | 4840 N CLOVERDALE RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837132423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087068000 | ||||||||
| FaxNumber: | 2087068001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COWGILL | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
| AuthorizedOfficialMiddleName: | LYNNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2083814137 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.