Basic Information
| Provider Information | |||||||||
| NPI: | 1861423410 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST LUKE'S REGIONAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | SLRMC PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 12/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | MOTES | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PFS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2087067062 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 03 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208M00000X | 03 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207RH0003X | 03 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207VM0101X | 03 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 208000000X | 03 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 03 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2085B0100X | 03 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 207P00000X | 03 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.