1649669953 NPI number — BIG SKY VASCULAR A SERIES OF TETON GROUP ENTERPRISES A DELAWARE LLC

Table of content: (NPI 1649669953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649669953 NPI number — BIG SKY VASCULAR A SERIES OF TETON GROUP ENTERPRISES A DELAWARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIG SKY VASCULAR A SERIES OF TETON GROUP ENTERPRISES A DELAWARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BIG SKY VASCULAR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649669953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1642
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83403-1642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-552-8761
Provider Business Mailing Address Fax Number:
208-523-2025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3307 GRAND AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILLINGS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59102-6551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-969-5194
Provider Business Practice Location Address Fax Number:
406-969-5195
Provider Enumeration Date:
01/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HODEL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
208-542-5000

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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