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DSH130006DS ST LUKES REGIONAL MEDICAL CENTER, LTD. (Terminated)
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Main Details
Name
ST LUKES REGIONAL MEDICAL CENTER, LTD.
Subdivision Name
PEDIATRIC MENTAL HEALTH
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130006DS
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
8/17/2015
Termination Date
Termination Reason
10/1/2015
Site closure
Contacts
Authorizing Official
St. Lukes Regional Medical Center
Peter DiDio, Vice President, Controller
(208) 381-1251
Primary Contact
Dawn Berheim, Senior Director of Pharmacy
(208) 381-7194
Addresses
Street Address
413 N. ALLUMBAUGH STE 102
BOISE, ID 83704
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
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