Provider Demographics
NPI:1154549616
Name:TETON PLASTIC SURGERY
Entity type:Organization
Organization Name:TETON PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-552-1406
Mailing Address - Street 1:PO BOX 1769
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1769
Mailing Address - Country:US
Mailing Address - Phone:208-552-1406
Mailing Address - Fax:208-552-1416
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 213
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-552-1406
Practice Address - Fax:208-552-1416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-82702086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-8270OtherID MEDICAL LICENSE
UT5959620-1205OtherUT MEDICAL LICENSE
UT5959620-8905OtherUT ST BOARD OF PHARMACY
WY6687AOtherWY MEDICAL LICENSE
IDCS9201OtherID ST BOARD OF PHARMACY
WY58MKM02OtherWY ST BOARD OF PHARMACY
ID04232007480947OtherDR.MOORE NPI TRCKNG#
ID04232007480947OtherDR.MOORE NPI TRCKNG#
ID04232007480947OtherDR.MOORE NPI TRCKNG#
IDF95588Medicare UPIN