NPIMap

Organization Active NPI

Grand Teton Medical Clinic

  • Urgent Care Clinic/Center
  • Moran, WY
National Provider Identifier
1891997151
Registry record updated Aug 2, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urgent Care Clinic/CenterTaxonomy code 261QU0200X
Legal business name
GRAND TETON MEDICAL CLINIC
Practice address
Inner Loop Road
Jackson Lake Lodge
Moran, WY 83013
Phone
(307) 543-2514
Fax
(307) 543-2514
NPI assigned
May 31, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 2, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Brent Blue, M.D.NPI 1063467538
Title
Clinic Owner
Phone
(307) 733-8002

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Urgent Care Clinic/Center 261QU0200X Primary

Addresses

Primary practice location

Inner Loop Road
Jackson Lake Lodge
Moran, WY 83013

Mailing address

PO Box 15240
Jackson, WY 83002-5240
Phone (307) 733-8002

Other identifiers 1

IdentifierTypeStateIssuer
1096516-00MedicaidWY

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1180569600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1186012800000",
    "number": "1891997151",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 15240",
            "city": "JACKSON",
            "state": "WY",
            "postal_code": "830025240",
            "telephone_number": "307-733-8002",
            "fax_number": "307-733-0032"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "INNER LOOP ROAD",
            "address_2": "JACKSON LAKE LODGE",
            "city": "MORAN",
            "state": "WY",
            "postal_code": "83013",
            "telephone_number": "307-543-2514",
            "fax_number": "307-543-2514"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND TETON MEDICAL CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-31",
        "last_updated": "2007-08-02",
        "status": "A",
        "authorized_official_last_name": "BLUE",
        "authorized_official_first_name": "BRENT",
        "authorized_official_title_or_position": "CLINIC OWNER",
        "authorized_official_telephone_number": "307-733-8002",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1096516-00",
            "state": "WY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Moran, WY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 2, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.