Basic Information
| Provider Information | |||||||||
| NPI: | 1972891604 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKES CLINIC - WOOD RIVER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 640 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837010640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | KETCHUM | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833409999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087278100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2011 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | SYSTEM VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 2083812520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST LUKES MEDICAL CENTER WOODRIVER LTD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 62 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207P00000X | 62 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 62 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | 62 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | 62 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208800000X | 62 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207R00000X | 62 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.