Provider Demographics
NPI:1043779127
Name:TETON SURGICAL SPECIALTIES PLLC
Entity Type:Organization
Organization Name:TETON SURGICAL SPECIALTIES PLLC
Other - Org Name:TETON HAND SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / MD
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-919-4263
Mailing Address - Street 1:3369 MERLIN DR STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7405
Mailing Address - Country:US
Mailing Address - Phone:844-919-4263
Mailing Address - Fax:833-513-0980
Practice Address - Street 1:3369 MERLIN DR STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7405
Practice Address - Country:US
Practice Address - Phone:844-919-4263
Practice Address - Fax:833-513-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-18
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1326240425Medicaid