Basic Information
| Provider Information | |||||||||
| NPI: | 1427574987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TETON SPORTS & SPINE IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3083 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003385378 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 SCOTT LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830018060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072015380 | ||||||||
| FaxNumber: | 3072015202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2017 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | ANDRIKOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3072015380 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 1427574987 | 05 | WY | MEDICAID |