Basic Information
| Provider Information | |||||||||
| NPI: | 1306137633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKES IDAHO CARDIOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 SUNSET DR | ||||||||
| Address2: | PO BOX 3290 | ||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419631555 | ||||||||
| FaxNumber: | 5419631845 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E HAWAII AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221680 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | MATTES | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5419631454 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GRANDE RONDE HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 140728 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.