MEDICARE: TETON SPORTS & SPINE IMAGING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center
2	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427574987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TETON SPORTS & SPINE IMAGING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 736
Second Line	:
City	:	WHEAT RIDGE
State	:	CO
Zip	:	80034-0736
Country	:	US
Telephone Number	:	307-218-8225
Fax Number	:	307-218-8226

Provider Business Practice Location Address
First Line	:	250 SCOTT LN STE 110
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8060
Country	:	US
Telephone Number	:	307-201-5380
Fax Number	:	307-201-5202

Authorized Official
Title or Position	:	MANAGER/PARTNER
Name	:	SHAUN ANDRIKOPOULOS
Credential	:
Telephone Number	:	307-201-5380

Provider Enumeration Date	:	08/16/2017
Last Update Date	:	09/26/2024

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Directions to “TETON SPORTS & SPINE IMAGING, LLC ” Practice Location

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