MEDICARE: TETON VALLEY HOSPITAL & SURGICENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	HH-184	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000010033856	OTHER	ID	REGENCE BLUE SHIELD OF ID
3	02592	OTHER	ID	BLUE CROSS OF IDAHO

General Provider Information

NPI Number	:	1770504391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TETON VALLEY HOSPITAL & SURGICENTER

Provider Business Mailing Address
First Line	:	120 E HOWARD ST
Second Line	:
City	:	DRIGGS
State	:	ID
Zip	:	83422-5112
Country	:	US
Telephone Number	:	208-354-6317
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 E HOWARD ST
Second Line	:
City	:	DRIGGS
State	:	ID
Zip	:	83422-5112
Country	:	US
Telephone Number	:	208-354-6317
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. SUSAN KUNZ
Credential	:
Telephone Number	:	208-354-6317

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	08/22/2020

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Directions to “TETON VALLEY HOSPITAL & SURGICENTER ” Practice Location

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