Provider Demographics
NPI:1487818605
Name:TETON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:TETON COUNTY HOSPITAL DISTRICT
Other - Org Name:ST JOHN'S HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-739-7526
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-733-3636
Mailing Address - Fax:877-205-2024
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-733-3636
Practice Address - Fax:877-205-2024
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-16
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15109208D00000X
273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No273Y00000XHospital UnitsRehabilitation UnitGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806430200Medicaid
WY1062999-09Medicaid
ID806430200Medicaid
WY1062999-09Medicaid