Provider Demographics
NPI:1528417938
Name:GRAND TETON ANESTHESIA, LLC
Entity Type:Organization
Organization Name:GRAND TETON ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:ZELEZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-803-6823
Mailing Address - Street 1:150 BUFFALO WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001
Mailing Address - Country:US
Mailing Address - Phone:404-803-6823
Mailing Address - Fax:
Practice Address - Street 1:150 BUFFALO WAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:404-803-6823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty