Provider Demographics
NPI:1639322258
Name:GRAND TETON CHILD NEUROLOGY
Entity Type:Organization
Organization Name:GRAND TETON CHILD NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:W
Authorized Official - Last Name:CASTELLANOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-529-4300
Mailing Address - Street 1:2225 TETON PLZ STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6494
Mailing Address - Country:US
Mailing Address - Phone:208-529-4300
Mailing Address - Fax:208-881-5121
Practice Address - Street 1:2225 TETON PLZ STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6494
Practice Address - Country:US
Practice Address - Phone:208-529-4300
Practice Address - Fax:208-529-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID77234OtherBLUE CROSS OF IDAHO
ID807968700Medicaid