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DSH130006HU 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 / Hays Street Medical Plaza St. Lukes CHILDRENS MENTAL HEALTH
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH130006HU
Medicare Provider Number
130006
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/4/2016
Participating Start Date
7/1/2016
Participating Approval Date
5/18/2016
Last Recertification Date
8/22/2016
Termination Date
Termination Reason
1/1/2018
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
608 W HAYES 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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