Healthcare Provider Details

I. General information

NPI: 1336920420
Provider Name (Legal Business Name): TETON RADIOLOGY CALDWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 ENTERPRISE WAY
CALDWELL ID
83605-8055
US

IV. Provider business mailing address

2001 S WOODRUFF AVE STE 17
IDAHO FALLS ID
83404-6372
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-0742
  • Fax: 208-455-7538
Mailing address:
  • Phone: 208-524-7237
  • Fax: 208-522-3017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN J STROBEL
Title or Position: OWNER
Credential: MD
Phone: 208-542-5000