Healthcare Provider Details

I. General information

NPI: 1639556376
Provider Name (Legal Business Name): TETON CANCER INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1957 E 17TH ST
IDAHO FALLS ID
83404-6429
US

IV. Provider business mailing address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1100
  • Fax:
Mailing address:
  • Phone: 208-523-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. NED HILLYARD
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 208-557-2711