Provider Demographics
NPI:1649669953
Name:BIG SKY VASCULAR A SERIES OF TETON GROUP ENTERPRISES A DELAWARE LLC
Entity type:Organization
Organization Name:BIG SKY VASCULAR A SERIES OF TETON GROUP ENTERPRISES A DELAWARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HODEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-542-5000
Mailing Address - Street 1:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1642
Mailing Address - Country:US
Mailing Address - Phone:208-552-8761
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:3307 GRAND AVE STE 201
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6551
Practice Address - Country:US
Practice Address - Phone:406-969-5194
Practice Address - Fax:406-969-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-10
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty