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General NPI Number Information
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NPI Number | 1407081060
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Entity Type | Organization
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Legal Business Name | TETON RADIOLOGY MADISON LLC
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Dates
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Enumeration Date | 05/26/2009
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Last Update Date | 01/10/2015
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Provider Practice Location Address
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Address Line | 425 E 4TH N
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City | REXBURG
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State | ID
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Zip | 83440-5390
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Country | US
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Telephone | 208-356-4888
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3007
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City | IDAHO FALLS
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State | ID
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Zip | 83403-3007
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Country | US
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Telephone | 208-552-8772
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Fax | 208-523-2025
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Authorized Official
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Title or Position | VP
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Name | JOHN J STROBEL
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Credential | MD
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Telephone | 208-542-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085B0100X
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Taxonomy Name | Body Imaging Physician
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License Number |
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License Number State |
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