Provider Demographics
NPI:1154390938
Name:GRAND TETON GASTROENTEROLOGY, PA
Entity type:Organization
Organization Name:GRAND TETON GASTROENTEROLOGY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:LEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:CCS-P
Authorized Official - Phone:208-528-4255
Mailing Address - Street 1:2770 CORTEZ AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7590
Mailing Address - Country:US
Mailing Address - Phone:208-522-4000
Mailing Address - Fax:208-528-4242
Practice Address - Street 1:2770 CORTEZ AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7590
Practice Address - Country:US
Practice Address - Phone:208-522-4000
Practice Address - Fax:208-528-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002708500Medicaid
ID0341440001Medicare NSC
ID002708500Medicaid