1770873572 NPI number — ST LUKES IDAHO CARDIOLOGY ASSOCIATES

Table of content: (NPI 1770873572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770873572 NPI number — ST LUKES IDAHO CARDIOLOGY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKES IDAHO CARDIOLOGY ASSOCIATES
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:
Provider Other Organization Name Type Code:
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:
1770873572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 SUNSET DR
Provider Second Line Business Mailing Address:
PO BOX 3290
Provider Business Mailing Address City Name:
LA GRANDE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97850-1362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-963-1555
Provider Business Mailing Address Fax Number:
541-963-1845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 E ELM ST
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-6363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MATTES
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
541-963-1454

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  140728 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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