# TETON RADIOLOGY DIAGNOSTIC A SERIES OF TETON GROUP ENTERPRISE

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Teton Radiology, Teton Radiology Diagnostic LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1013085604
- **Authorized official:** MR. MICHAEL P HODEL (GENERAL MANAGER)
- **Authorized official phone:** (208) 542-5000

## Contact information

- **Practice address:** 2001 S WOODRUFF AVE STE 17, IDAHO FALLS, ID 83404-6372
- **Practice address phone:** (208) 524-7237
- **Mailing address:** PO BOX 30015, DEPT 594, SALT LAKE CITY, UT 84130-0015
- **Mailing address phone:** (800) 475-6236
- **Mailing address fax:** (706) 596-6712

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2085B0100X | Body Imaging Physician | — | NULL | Yes |
| 2085B0100X | Body Imaging Physician | — | — | Yes |
| 2085N0700X | Neuroradiology Physician | — | NULL | — |
| 2085N0700X | Neuroradiology Physician | — | — | — |
| 2085N0904X | Nuclear Radiology Physician | — | NULL | — |
| 2085N0904X | Nuclear Radiology Physician | — | — | — |
| 2085P0229X | Pediatric Radiology Physician | — | NULL | — |
| 2085P0229X | Pediatric Radiology Physician | — | — | — |
| 2085R0001X | Radiation Oncology Physician | — | NULL | — |
| 2085R0001X | Radiation Oncology Physician | — | — | — |
| 2085R0202X | Diagnostic Radiology Physician | — | NULL | — |
| 2085R0202X | Diagnostic Radiology Physician | — | — | — |
| 2085R0203X | Therapeutic Radiology Physician | — | NULL | — |
| 2085R0203X | Therapeutic Radiology Physician | — | — | — |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | NULL | — |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | — | — |
| 2085R0205X | Radiological Physics Physician | — | NULL | — |
| 2085R0205X | Radiological Physics Physician | — | — | — |
| 2085U0001X | Diagnostic Ultrasound Physician | — | NULL | — |
| 2085U0001X | Diagnostic Ultrasound Physician | — | — | — |

## Other

- **Enumeration date:** 12/01/2006
- **Last updated:** 01/05/2026

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 807617900 | — | ID |
| 01 | — | DF6608 | RAILROAD MEDICARE | — |