Healthcare Provider Details

I. General information

NPI: 1194969725
Provider Name (Legal Business Name): TETON RADIOLOGY DIAGNOSTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 2147
IDAHO FALLS ID
83403-2147
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7237
  • Fax:
Mailing address:
  • Phone: 208-552-8769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL P HODEL
Title or Position: GENERAL MANAGER
Credential:
Phone: 208-542-5000