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DSH130006EF ST LUKES REGIONAL MEDICAL CENTER, LTD. (Terminated)
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Main Details
Name
ST LUKES REGIONAL MEDICAL CENTER, LTD.
Subdivision Name
SL CLINIC-AD LAPAROSCOPIC SURGERY
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130006EF
Medicare Provider Number
130006
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/14/2014
Participating Start Date
7/1/2014
Participating Approval Date
5/22/2014
Last Recertification Date
8/27/2018
Termination Date
Termination Reason
10/1/2018
Site closure
Contacts
Authorizing Official
St. Lukes Regional Medical Center
Peter DiDio, Vice President, Controller
(208) 381-1251
Primary Contact
St. Luke's Health System, LTD
Amanda Davis, Pharmacy Business Analyst
(208) 706-1021
Addresses
Street Address
222 N. 2ND ST. STE 201
BOISE, ID 83702
Billing Address
St. Lukes Health System, LTD
190 E Bannock
Boise, ID 83712
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
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