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DSH130006DN 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
DSH130006DN
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
8/18/2016
Termination Date
Termination Reason
4/1/2017
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
450 W. STATE ST. STE 100
EAGLE, ID 83616
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
June 2025
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