Basic Information
| Provider Information | |||||||||
| NPI: | 1508224379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TETON VASCULAR INSTITUTE OF POCATELLO A SERIES OF TETON GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1406 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834031406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085528576 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 HOSPITAL WAY BLDG 100 | ||||||||
| Address2: | STE 111 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082328346 | ||||||||
| FaxNumber: | 2082332272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 02/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | HODEL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2085425000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.