Provider Demographics
NPI:1780625632
Name:TETON VALLEY HOSPITAL & SURGICENTER
Entity type:Organization
Organization Name:TETON VALLEY HOSPITAL & SURGICENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PIQUET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-354-6302
Mailing Address - Street 1:120 EAST HOWARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-2302
Mailing Address - Fax:208-354-8392
Practice Address - Street 1:283 N 1ST STREET
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5112
Practice Address - Country:US
Practice Address - Phone:208-354-2302
Practice Address - Fax:208-354-8392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON VALLEY HOSPITAL & SURGICENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-10
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID31207X00000X, 208000000X, 208VP0014X, 208600000X, 208800000X, 1041C0700X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010159438OtherREGENCE BLUE SHIELD
ID807736200Medicaid
ID8M953OtherBLUE CROSS
FL9122702-00Medicaid
ID807736200Medicaid
ID000010159438OtherREGENCE BLUE SHIELD
ID133848Medicare ID - Type UnspecifiedRHC