Provider Demographics
NPI:1194969725
Name:TETON RADIOLOGY DIAGNOSTIC, LLC
Entity type:Organization
Organization Name:TETON RADIOLOGY DIAGNOSTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HODEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-542-5000
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2147
Mailing Address - Country:US
Mailing Address - Phone:208-552-8769
Mailing Address - Fax:
Practice Address - Street 1:2001 S WOODRUFF AVE STE 17
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6372
Practice Address - Country:US
Practice Address - Phone:208-524-7237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON RADIOLOGY DIAGNOSITC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty