St Luke'S Clinic LLC
Organization Active NPI Family Medicine Physician · Twin Falls, ID
NPI 1790718229 · NPPES record last updated Apr 23, 2026
Key facts
- NPI
- 1790718229
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- ST LUKE'S CLINIC LLC
- Practice address
- 775 Pole Line Rd W
Twin Falls, ID 83301-5814 - Phone
- (208) 814-1000
- NPI assigned
- Jul 8, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTD
Authorized official
- Name
- Kathryn Fowler
- Title
- Senior VP, Cfo
- Phone
- (208) 381-8717
Owners & managing parties with NPI records 7
-
Lucie A Dimaggio, M.D.
Member of 1
Member organizations 1
Related certifications (CCN) 1
Facilities with the same owner 19
Practitioners 485
-
Elliot McNamara Adams, M.D.
-
Jessica Rose Adamson, MSN, APRN, FNP-C
-
Nathan Kent Allen, D.O.
-
John Roger Anderson, D.O.
-
Kelly Curtis Anderson, D.O.
-
Logan Anderson, DO
-
Thomas C Ashby, M.D.
-
Eric Leon Bailey, CRNA
-
John A Baker, M.D.
-
Gregory R Ball, DO
-
Samuel Fox Barker, M.D.
-
Donna Lynn Benjamin, PSY.D., LCSW
-
Umesh Chander Bhandari, M.D.
-
Lindsey Blamires, FNP-BC
-
Amanda Paige Braga, LCSW
-
Demsie M Butler, MD
-
Cade Call, DO
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 13D2172039 | St Luke'S Clinic Jerome Family Medicine | Provider-performed microscopy | Sep 12, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (18 enrollments) in ID, NV, CO, DC, GA, AZ, KS, HI, OH, OR, VA, WA, MA, FL, WI, TX, MI
Rural health clinic certification: CCN 133992
- Legal name
- ST LUKES CLINIC LLC
- Doing business as
- ST LUKES CLINIC JEROME FAMILY MEDICINE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Nov 3, 1999
- Last certification
- Feb 19, 2004
- Ownership / control type
- 2B
- Most recent change of ownership
- Oct 1, 2013 (1 total)
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 18, 2000 in ID
- Enrollment address
- 132 5TH Ave W Ste 1/2
Jerome, ID 83338-1825 - Related CCNs
- 131310
All disclosed owners & managing parties 22
| Name | Role | Since | Share |
|---|---|---|---|
| Durmot Mark Durcan |
Corporate Director |
Oct 1, 2018 | |
| Lisa Grow |
Corporate Director |
Oct 1, 2018 | |
| Emily Baker |
Corporate Director |
Nov 1, 2021 | |
| Allan Korn |
Corporate Director |
Oct 1, 2018 | |
| Robert Lokken |
Corporate Director |
Oct 1, 2018 | |
| Andrew Scoggin |
Corporate Director |
Oct 1, 2018 | |
| Richard Raimondi |
Corporate Director |
Oct 1, 2018 | |
| Lucie a Dimaggio |
Corporate Director |
Oct 1, 2018 | |
| Daniel Krahn |
Corporate Director |
Oct 1, 2018 | |
| St Lukes Health System LTD |
5% Or Greater Indirect Ownership Interest | Oct 1, 2011 | 100% |
| Jared Grant |
Corporate Officer |
Jan 19, 2023 | |
| W-2 Managing Employee |
Jan 19, 2023 | ||
| St Lukes Magic Valley Regional Medical Center LTD |
5% Or Greater Direct Ownership Interest | Oct 1, 2011 | 100% |
| Jacob Reid |
Corporate Officer |
Sep 1, 2023 | |
| W-2 Managing Employee |
Sep 1, 2023 | ||
| Kathryn Fowler |
Corporate Director |
Feb 1, 2021 | |
| W-2 Managing Employee |
Feb 1, 2021 | ||
| Rosa Davila |
Corporate Director |
Sep 30, 2021 | |
| William Gilbert |
Corporate Director |
Nov 1, 2022 | |
| William Whitacre |
Corporate Director |
Oct 1, 2018 | |
| Christopher Roth |
Corporate Officer |
Jan 31, 2020 | |
| Corporate Director |
Jan 31, 2020 | ||
| W-2 Managing Employee |
Jan 31, 2020 | ||
| Jill Twedt |
Corporate Director |
Nov 1, 2022 | |
| Robert Mueller |
Corporate Director |
Oct 1, 2015 | |
| W-2 Managing Employee |
Oct 1, 2015 | ||
| Operational/Managerial Control |
Oct 1, 2015 | ||
| Thomas K Corrick |
Corporate Director |
Oct 1, 2018 | |
| William Ystueta Jr |
Corporate Director |
Oct 1, 2023 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031208000899 | ID | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 344 practitioners Practice locations: Twin Falls, ID; Boise, ID; Buhl, ID; Coeur D Alene, ID; Hailey, ID; Jerome, ID |
| O20090825000091 | NV | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Reno, NV |
| O20140611002216 | ID | Part a Provider - Rural Health Clinic | 1052217478 | Practice locations: Jerome, ID |
| O20210720002830 | CO | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 3 practitioners Practice locations: Colorado Springs, CO; Denver, CO |
| O20210812000233 | DC | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Alexandria, VA |
| O20210817000394 | GA | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Clayton, GA |
| O20210817001980 | AZ | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Chandler, AZ |
| O20210819001777 | KS | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Hays, KS; Topeka, KS |
| O20210820002231 | HI | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Honolulu, HI |
| O20210823002996 | OH | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: New Albany, OH |
| O20210825002724 | OR | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: La Grande, OR |
| O20210908001455 | VA | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 3 practitioners Practice locations: Leesburg, VA; Earlysville, VA; Virginia Beach, VA; Middleburg, VA |
| O20210917002758 | WA | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Bellevue, WA; Bothell, WA |
| O20210921002968 | MA | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 2 practitioners Practice locations: Boxford, MA; Lexington, MA |
| O20211006003232 | FL | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 4 practitioners Practice locations: Beverly Hills, FL; Melbourne Beach, FL; Sarasota, FL; Wellington, FL |
| O20211208001162 | WI | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Beloit, WI |
| O20220713002850 | TX | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: Houston, TX |
| O20230110000595 | MI | Part B Supplier - Clinic/Group Practice | 1052217478 |
Receives reassigned benefits from 1 practitioner Practice locations: West Bloomfield, MI |
National Provider Directory
- Part of
- SLMV Medical Center
Locations (25 of 56)
1491 Parkway Dr
Blackfoot, ID 83221
Phone (208) 435-2379
510 N 2nd St
Boise, ID 83702
Phone (208) 385-3440
600 N Robbins Rd
Ste 102
Boise, ID 83702
Phone (208) 706-7500
720 E Park Blvd
Ste 200
Boise, ID 83712
Phone (208) 381-3939
510 N 2nd St
Ste 201
Boise, ID 83702
Phone (208) 385-3440
980 Burley Ave
Buhl, ID 83316
Phone (208) 814-9150
741 N Overland Ave
Burley, ID 83318
Phone (208) 677-5483
132 5th Ave W
Ste 2
Jerome, ID 83338
Phone (208) 324-5286
128 5th Ave W
Jerome, ID 83338
Phone (208) 324-3090
132 5th Ave W
Jerome, ID 83338
Phone (207) 324-4992
520 S Eagle Rd
Ste 2104
Meridian, ID 83642
Phone (208) 706-0201
9850 W St Lukes Dr
Ste 207
Nampa, ID 83687
Phone (208) 505-2000
1308 8th St
Ste 201
Rupert, ID 83350
1308 8th St
Rupert, ID 83350
Phone (208) 436-4322
775 Pole Line Rd W
Ste 315
Twin Falls, ID 83301
Phone (208) 814-8750
730 N College Rd
Ste Ab
Twin Falls, ID 83301
630 Addison Ave W
Ste 100
Twin Falls, ID 83301
Phone (208) 733-1665
625 Pole Line Rd W
Ste 2A
Twin Falls, ID 83301
Phone (208) 814-8600
625 Pole Line Rd W
Ste 2B
Twin Falls, ID 83301
Phone (208) 814-5300
630 Addison Ave W
#100
Twin Falls, ID 83301
Phone (208) 733-4343
660 Shoshone St E
#201
Twin Falls, ID 83301
Phone (208) 732-3040
801 Pole Line Rd W
Rm H1155
Twin Falls, ID 83301
Phone (208) 814-1016
630 Addison Ave W
Ste 240
Twin Falls, ID 83301
Phone (208) 734-3041
450 Falls Ave
Ste 202
Twin Falls, ID 83301
Phone (208) 814-9075
754 N College Rd
Ste A
Twin Falls, ID 83301
Phone (208) 814-7770
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Internal Medicine Physician |
207R00000X | |||
| Cardiovascular Disease Physician |
207RC0000X | |||
| Nephrology Physician |
207RN0300X | |||
| Pediatrics Physician |
208000000X | |||
| Occupational Medicine Physician |
2083X0100X | |||
| Surgery Physician |
208600000X | |||
| Rural Health Clinic/Center | 261QR1300X |
Addresses
Primary practice location
775 Pole Line Rd W
Twin Falls, ID 83301-5814
Mailing address
PO Box 640
Boise, ID 83701-0640
Phone (208) 706-5000
Other practice location 1
132 5th Ave W Ste 1/2
Jerome, ID 83338-1825
Phone (208) 814-9800
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 806593000 | Medicaid | ID | |
| 1257846 | Other | ID | MEDICARE - CLINIC |
| 133992 | Other | ID | MEDICARE - RHC |
| DA1879 | Other | ID | RR MEDICARE |
Other names
- St Lukes Clinic - Magic Valley/Jerome
- St Lukes Jerome RHC
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service | Other | eSolutions Inc |
Other providers in Twin Falls, ID
- Spinal Rehab of North County
- Michael William Sprague
- David M Spritzer
- Abigail Hodges Sproul
- Julie Waite St Clair
- St Luke'S Clinic, LLC
- St Luke'S Magic Valley Regional Medical Center LTD
- St Lukes Magic Valley Regional Medical Center
- St Lukes Magic Valley Regional Medical Center LTD
- St Lukes Magic Valley Regional Medical Center LTD
All providers in Twin Falls, ID · Family Medicine Physician in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 23, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.