Basic Information
| Provider Information | |||||||||
| NPI: | 1407081060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TETON RADIOLOGY MADISON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3007 | ||||||||
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| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085528772 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 E 4TH N | ||||||||
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| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834405390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083564888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2009 | ||||||||
| LastUpdateDate: | 01/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | STROBEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2085425000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No ID Information.