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DSH130006HD ST. LUKES REGIONAL MEDICAL CENTER (Terminated)
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Main Details
Name
ST. LUKES REGIONAL MEDICAL CENTER
Subdivision Name
SSOP SLC SPORTS MEDICINE CONCUSSION CLINIC
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130006HD
Medicare Provider Number
130006
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/10/2015
Participating Start Date
10/1/2015
Participating Approval Date
8/7/2015
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
111 WEST STATE STREET
BOISE, ID 83702
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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