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General NPI Number Information
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NPI Number | 1508224379
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Entity Type | Organization
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Legal Business Name | TETON VASCULAR INSTITUTE OF POCATELLO A SERIES OF TETON GROUP
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Dates
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Enumeration Date | 02/08/2016
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Last Update Date | 02/09/2018
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Provider Practice Location Address
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Address Line | 444 HOSPITAL WAY BLDG 100 STE 111
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City | POCATELLO
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State | ID
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Zip | 83201-2745
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Country | US
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Telephone | 208-232-8346
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Fax | 208-233-2272
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Provider Business Mailing Address
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Address Line | PO BOX 1406
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City | IDAHO FALLS
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State | ID
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Zip | 83403-1406
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Country | US
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Telephone | 208-552-8576
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Fax | 208-523-2025
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Authorized Official
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Title or Position | CEO
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Name | MR. MICHAEL P HODEL
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Credential |
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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 | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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