Healthcare Provider Details

I. General information

NPI: 1669586632
Provider Name (Legal Business Name): JACKSON HOLE MEDICAL IMAGING, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E BROADWAY ST JOHNS MEDICAL CENTER-DEPT OF RADIOLOGY
JACKSON WY
83001-9496
US

IV. Provider business mailing address

PO BOX 7746
JACKSON WY
83002-7746
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-5229
  • Fax:
Mailing address:
  • Phone: 903-274-3063
  • Fax: 314-548-4748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER SEAN HALING
Title or Position: PRESIDENT
Credential: MD
Phone: 307-739-7280