Basic Information
| Provider Information | |||||||||
| NPI: | 1881896694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TETON COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST JOHNS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 428 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077333636 | ||||||||
| FaxNumber: | 3077397522 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 EAST BROADWAY | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077333636 | ||||||||
| FaxNumber: | 3077397522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 06/06/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLASEN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 3077397559 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 07109 | WY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 106299904 | 05 | WY | MEDICAID |