Provider Demographics
NPI:1154502615
Name:TETON MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:TETON MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-356-7585
Mailing Address - Street 1:32 WEST 1ST SOUTH
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1810
Mailing Address - Country:US
Mailing Address - Phone:208-356-7585
Mailing Address - Fax:208-356-7566
Practice Address - Street 1:32 W 1ST S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1810
Practice Address - Country:US
Practice Address - Phone:208-356-7585
Practice Address - Fax:208-356-7566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11001041Medicare PIN