Provider Demographics
NPI:1891997151
Name:GRAND TETON MEDICAL CLINIC
Entity Type:Organization
Organization Name:GRAND TETON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-733-8002
Mailing Address - Street 1:PO BOX 15240
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-5240
Mailing Address - Country:US
Mailing Address - Phone:307-733-8002
Mailing Address - Fax:307-733-0032
Practice Address - Street 1:INNER LOOP ROAD
Practice Address - Street 2:JACKSON LAKE LODGE
Practice Address - City:MORAN
Practice Address - State:WY
Practice Address - Zip Code:83013
Practice Address - Country:US
Practice Address - Phone:307-543-2514
Practice Address - Fax:307-543-2514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1096516-00Medicaid
WY1096516-00Medicaid