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DSH130006DP ST LUKES REGIONAL MEDICAL CENTER, LTD. (Terminated)
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Main Details
Name
ST LUKES REGIONAL MEDICAL CENTER, LTD.
Subdivision Name
ST LUKES CHILDHOOD OBESITY
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130006DP
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
8/24/2019
Termination Date
Termination Reason
1/1/2020
Other
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
100 E Idaho Street Suite 200
Boise, ID 83712
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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