1508869470 NPI number — ST LUKES MEDICAL CENTER WOOD RIVER LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508869470 NPI number — ST LUKES MEDICAL CENTER WOOD RIVER LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKES MEDICAL CENTER WOOD RIVER LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST LUKES WOOD RIVER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508869470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2777
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83701-2777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-706-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340-9999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-727-8100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
208-381-2520

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  62 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 805909800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".