Provider Demographics
NPI:1659426617
Name:TETON CANCER INSTITUTE
Entity Type:Organization
Organization Name:TETON CANCER INSTITUTE
Other - Org Name:TETON CANCER INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:NED
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLYARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-577-2711
Mailing Address - Street 1:2325 CORONADO STREET
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-557-2700
Mailing Address - Fax:208-557-2701
Practice Address - Street 1:1957 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6429
Practice Address - Country:US
Practice Address - Phone:208-523-1100
Practice Address - Fax:208-557-2701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN VIEW HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-23
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
13-0065Medicare UPIN