Basic Information
| Provider Information | |||||||||
| NPI: | 1649474362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TETON INTERNAL MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2257 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834032257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252662 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 EAST BROADWAY | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077337222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUTCHER | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3077337222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.