Provider Demographics
NPI:1801835475
Name:TETON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:TETON COUNTY HOSPITAL DISTRICT
Other - Org Name:ST. JOHN'S MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15109275N00000X, 282N00000X
347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106299900Medicaid
WY106299904Medicaid
WY106299917Medicaid