Provider Demographics
NPI:1508224379
Name:TETON VASCULAR INSTITUTE OF POCATELLO A SERIES OF TETON GROUP
Entity Type:Organization
Organization Name:TETON VASCULAR INSTITUTE OF POCATELLO A SERIES OF TETON GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HODEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-542-5000
Mailing Address - Street 1:PO BOX 1406
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1406
Mailing Address - Country:US
Mailing Address - Phone:208-552-8576
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:444 HOSPITAL WAY BLDG 100
Practice Address - Street 2:STE 111
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2745
Practice Address - Country:US
Practice Address - Phone:208-232-8346
Practice Address - Fax:208-233-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty