Basic Information
| Provider Information | |||||||||
| NPI: | 1932154705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S MAGIC VALLEY REGIONAL MEDICAL CENTER, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2777 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837012777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087065000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 POLE LINE RD W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088141000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO, VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2083812520 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | 14 | ID | N | Suppliers | Pharmacy | Institutional Pharmacy | 341600000X | ID | N | Transportation Services | Ambulance | 3416A0800X | N | Transportation Services | Ambulance | Air Transport | 282N00000X | 14 | ID | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000010006647 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER | 807496600 | 05 | ID | MEDICAID | 00018 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |