Provider Demographics
NPI:1821317595
Name:TETON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:TETON COUNTY HOSPITAL DISTRICT
Other - Org Name:ST JOHNS MEDICAL CENTER ER PHYSICIANS
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:307-739-7250
Mailing Address - Fax:307-739-7249
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HOLE
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-739-7250
Practice Address - Fax:307-739-7249
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-20
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15109207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106299910Medicaid
WYW4251501Medicare PIN