NPIMap

Organization Active NPI

St Luke's Clinic LLC

Doing business as St Lukes Clinic - Magic Valley/Jerome

  • Family Medicine Physician
  • Twin Falls, ID
National Provider Identifier
1790718229
Registry record updated Apr 23, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ST LUKE'S CLINIC LLC
Doing business as
St Lukes Clinic - Magic Valley/Jerome
St Lukes Jerome RHC
Practice address
775 Pole Line Rd W
Twin Falls, ID 83301-5814
Phone
(208) 814-1000
NPI assigned
Jul 8, 2006
Last updated
Apr 23, 2026By the provider in NPPES
Organization subpart
Yes
Parent organization
ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTDAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 23, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kathryn Fowler
Title
Senior VP, Cfo
Phone
(208) 381-8717

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X
Family Medicine Physician 207Q00000X Primary
Internal Medicine Physician 207R00000X
Cardiovascular Disease Physician 207RC0000X
Nephrology Physician 207RN0300X
Pediatrics Physician 208000000X
Occupational Medicine Physician 2083X0100X
Surgery Physician 208600000X

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 4

IdentifierTypeStateIssuer
DA1879OtherIDRR MEDICARE
1257846OtherIDMEDICARE - CLINIC
133992OtherIDMEDICARE - RHC
806593000MedicaidID

Other names 2

  • St Lukes Clinic - Magic Valley/Jerome Doing business as
  • St Lukes Jerome RHC Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service Other eSolutions Inc

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID, NV, CO, DC, GA, AZ, KS, HI, OH, OR, VA, WA, MA, FL, WI, TX, MI18 enrollments

Enrollment records 18

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790718229. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Dec 18, 2000 in ID
Enrollment address
132 5TH Ave W Ste 1/2
Jerome, ID 83338-1825
Related CCNs
131310

Facilities connected through Provider of Services related, parent or unit certification numbers.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D2172039St Luke's Clinic Jerome Family Medicine132 5TH Ave West, Jerome, ID 83338Provider-performed microscopySep 12, 2027

National Provider Directory

National Provider Directory
Part of
St Lukes Jerome

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations (25 of 36)

100 E Warm Springs Ave
#B
Boise, ID 83712
Phone (208) 381-6930

510 N 2nd St
Boise, ID 83702
Phone (208) 385-3440

701 E Parkcenter Blvd
Boise, ID 83706
Phone (208) 381-6400

1450 Aviation Dr
Ste 203
Hailey, ID 83333
Phone (208) 727-8295

132 5th Ave W
Ste 12
Jerome, ID 83338
Phone (208) 814-9800

520 S Eagle Rd
Ste 2104
Meridian, ID 83642
Phone (208) 706-0201

520 S Eagle Rd
Ste 2213
Meridian, ID 83642
Phone (208) 706-5447

9850 W St Lukes Dr
Ste 180
Nampa, ID 83687

1218 9th St
Rupert, ID 83350
Phone (208) 678-4100

1308 8th St
Ste 201
Rupert, ID 83350

1235 Filer Ave E
Twin Falls, ID 83301
Phone (208) 595-2490

141 Morrison St
Twin Falls, ID 83301
Phone (208) 732-3030

2550 Addison Ave E
Ste F
Twin Falls, ID 83301
Phone (208) 814-7700

2550 Addison Ave E
Ste G
Twin Falls, ID 83301
Phone (208) 814-7750

450 Falls Ave
Ste 202
Twin Falls, ID 83301
Phone (208) 814-9075

601 Pole Line Rd
Ste 2
Twin Falls, ID 83301
Phone (208) 814-7600

601 Pole Line Rd
Ste 2A
Twin Falls, ID 83301

630 Addison Ave W
#100
Twin Falls, ID 83301
Phone (208) 733-4343

630 Addison Ave W
Ste 200
Twin Falls, ID 83301
Phone (208) 735-1000

630 Addison Ave W
Ste 240
Twin Falls, ID 83301
Phone (208) 734-3041

660 Shoshone St E
#100
Twin Falls, ID 83301
Phone (208) 732-3020

660 Shoshone St E
#140
Twin Falls, ID 83301
Phone (208) 732-3180

660 Shoshone St E
#201
Twin Falls, ID 83301
Phone (208) 732-3040

660 Shoshone St E
#220
Twin Falls, ID 83301
Phone (208) 732-3450

660 Shoshone St E
Ste 130
Twin Falls, ID 83301
Phone (208) 732-3200

Ownership & related parties

All disclosed owners & managing parties 22

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Durmot Mark Durcan Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
Lisa Grow Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
Emily Baker Individual Corporate DirectorBoard Member Nov 1, 2021
Allan Korn Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
Robert Lokken Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
Andrew Scoggin Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
Richard Raimondi Individual Corporate DirectorAt-Large, Chairman Oct 1, 2018
Lucie a Dimaggio Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
Daniel Krahn Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
St Lukes Health System LTD Organization, Boise, ID Non-profit 5% Or Greater Indirect Ownership Interest Oct 1, 2011 100%
Jared Grant Individual Corporate OfficerSystem Controller & Treasurer Jan 19, 2023
W-2 Managing EmployeeSystem Controller & Treasurer Jan 19, 2023
St Lukes Magic Valley Regional Medical Center LTD Organization, Twin Falls, ID Non-profit 5% Or Greater Direct Ownership Interest Oct 1, 2011 100%
Jacob Reid Individual Corporate OfficerPFM Administrator Sep 1, 2023
W-2 Managing EmployeePFM Administrator Sep 1, 2023
Kathryn Fowler Individual Corporate DirectorVP Operational Finance Feb 1, 2021
W-2 Managing EmployeeVP Operational Finance Feb 1, 2021
Rosa Davila Individual Corporate DirectorBoard Member Sep 30, 2021
William Gilbert Individual Corporate DirectorBoard Member Nov 1, 2022
William Whitacre Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
Christopher Roth Individual Corporate OfficerPresident & Ceo Jan 31, 2020
Corporate DirectorPresident & Ceo Jan 31, 2020
W-2 Managing EmployeePresident & Ceo Jan 31, 2020
Jill Twedt Individual Corporate DirectorBoard Member Nov 1, 2022
Robert Mueller Individual Corporate DirectorVP Revenue Cycle Oct 1, 2015
W-2 Managing EmployeeVP Revenue Cycle Oct 1, 2015
Operational/Managerial ControlVP Revenue Cycle Oct 1, 2015
Thomas K Corrick Individual Corporate DirectorAt-Large, Board Member Oct 1, 2018
William Ystueta Jr Individual Corporate DirectorBoard Member Oct 1, 2023

Owners & managing parties with NPI records 7

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 19

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 19

Practitioners & affiliated clinicians

Practitioners 485

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 485

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1776902400000",
    "number": "1790718229",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 640",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837010640",
            "telephone_number": "208-706-5000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "775 POLE LINE RD W",
            "city": "TWIN FALLS",
            "state": "ID",
            "postal_code": "833015814",
            "telephone_number": "208-814-1000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "132 5th Ave W Ste 1/2",
            "address_purpose": "LOCATION",
            "city": "Jerome",
            "state": "ID",
            "postal_code": "833381825",
            "country_code": "US",
            "telephone_number": "208-814-9800",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "ST LUKE'S CLINIC LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTD",
        "enumeration_date": "2006-07-08",
        "last_updated": "2026-04-23",
        "certification_date": "2026-04-23",
        "status": "A",
        "authorized_official_last_name": "FOWLER",
        "authorized_official_first_name": "KATHRYN",
        "authorized_official_title_or_position": "SENIOR VP, CFO",
        "authorized_official_telephone_number": "208-381-8717"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2083X0100X",
            "taxonomy_group": "",
            "desc": "Preventive Medicine, Occupational Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "DA1879",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE - CLINIC",
            "identifier": "1257846",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE - RHC",
            "identifier": "133992",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806593000",
            "state": "ID"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1066.1",
            "affiliationName": "eSolutions Inc",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "8215 W 108th Ter",
            "city": "Overland Park",
            "state": "KS",
            "country_code": "US",
            "postal_code": "662101661",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "St Lukes Clinic - Magic Valley/Jerome",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St Lukes Jerome RHC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Twin Falls, ID

Sources for this page

Verify at the official NPI Registry.