Basic Information
| Provider Information | |||||||||
| NPI: | 1669586632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON HOLE MEDICAL IMAGING, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JH MEDICAL IMAGING PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7746 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830027746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032743063 | ||||||||
| FaxNumber: | 3145484748 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 E BROADWAY | ||||||||
| Address2: | ST JOHNS MEDICAL CENTER-DEPT OF RADIOLOGY | ||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830019496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077335229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | HALING | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | SEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3077397280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0028898 | 05 | ID | MEDICAID | 303983 | 01 | WY | BCBS | OTHER | 107194700 | 05 | WY | MEDICAID |