MEDICARE: TETON VALLEY HOSPITAL & SURGICENTER

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	282NC0060X	Critical Access Hospital	31	ID

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	00273	OTHER	ID	BLUE CROSS
5	000010006342	OTHER	ID	REGENCE BLUE SHIELD

General Provider Information

NPI Number	:	1710959184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TETON VALLEY HOSPITAL & SURGICENTER

Provider Business Mailing Address
First Line	:	120 EAST HOWARD AVENUE
Second Line	:
City	:	DRIGGS
State	:	ID
Zip	:	83422-5112
Country	:	US
Telephone Number	:	208-354-2383
Fax Number	:	208-354-3158

Provider Business Practice Location Address
First Line	:	120 EAST HOWARD AVENUE
Second Line	:
City	:	DRIGGS
State	:	ID
Zip	:	83422-5112
Country	:	US
Telephone Number	:	208-354-2383
Fax Number	:	208-354-3158

Authorized Official
Title or Position	:	QUALITY SERVICES MANAGER
Name	:	MRS. LAURA C PIQUET
Credential	:
Telephone Number	:	205-354-6302

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	02/07/2012

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Directions to “TETON VALLEY HOSPITAL & SURGICENTER ” Practice Location

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