# ST LUKES REGIONAL MED CTR DBA ST LUKES PEDIATRIC SURGERY OF IDAHO

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1720204738
- **Authorized official:** MS. CARRIE L COWGILL (CREDENTIALING COORDINATOR)
- **Authorized official phone:** (208) 381-4137

## Contact information

- **Practice address:** 100 E IDAHO ST, SUITE 300, BOISE, ID 83712-6223
- **Practice address phone:** (208) 345-5400
- **Practice address fax:** (208) 345-5454
- **Mailing address:** 100 E IDAHO ST, SUITE 300, BOISE, ID 83712-6223
- **Mailing address phone:** (208) 345-5400
- **Mailing address fax:** (208) 345-5454

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2086S0120X | Pediatric Surgery Physician | — | NULL | Yes |
| 2086S0120X | Pediatric Surgery Physician | — | — | Yes |

## Other

- **Enumeration date:** 04/18/2007
- **Last updated:** 04/09/2008