Timothy Bock Icenogle, MD

Primary specialty

Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianTaxonomy code 208G00000X

License

126770044-1205 Issued in UT

Practice address

4403 Harrison Blvd Ste 3835
Ogden, UT 84403-3331

Phone

(801) 387-3475

Fax

(801) 387-3480

NPI assigned

May 9, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 4

Addresses

Other identifiers 3

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: ticenogle814231@direct.sw.org
• Direct secure messaging: ticenogle316027@direct.peacehealth.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• NW Cardiothoracic & Transplant Surgeons P.S.

  • Transplant Surgery Physician
  • Spokane, WA
  • NPI 1336194703

  Transplant Surgery

  NPD Authorized official
• Ihc Health Services Inc

  • Family Medicine Physician
  • Salt Lake City, UT
  • NPI 1306888722

  Thoracic Surgery (Cardiothoracic Vascular Surgery)

  NPD (past)
• Ihc Health Services Inc

  • Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
  • Ogden, UT
  • NPI 1962547695

  Thoracic Surgery (Cardiothoracic Vascular Surgery)

  NPD (past)

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

{
    "created_epoch": "1147132800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1670889600000",
    "number": "1285683029",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 27128",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841270128"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4403 HARRISON BLVD STE 3835",
            "city": "OGDEN",
            "state": "UT",
            "postal_code": "844033331",
            "telephone_number": "801-387-3475",
            "fax_number": "801-387-3480"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3415 W Horizon Ave",
            "address_purpose": "LOCATION",
            "city": "Spokane",
            "state": "WA",
            "postal_code": "992088493",
            "country_code": "US",
            "telephone_number": "509-220-1900",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "100 Hillcrest Medical Blvd",
            "address_purpose": "LOCATION",
            "city": "Waco",
            "state": "TX",
            "postal_code": "767128897",
            "country_code": "US",
            "telephone_number": "254-202-2000",
            "fax_number": "254-202-5849",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "ICENOGLE",
        "first_name": "TIMOTHY",
        "middle_name": "BOCK",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-09",
        "last_updated": "2022-12-13",
        "certification_date": "2022-12-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "204F00000X",
            "taxonomy_group": "",
            "desc": "Transplant Surgery",
            "state": "WA",
            "license": "MD00026659",
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "TX",
            "license": "S9004",
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "WA",
            "license": "MD00026659",
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "UT",
            "license": "126770044-1205",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1072495",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3756900",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3505645",
            "state": "MT"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "ticenogle814231@direct.sw.org",
            "affiliation": "N",
            "address_1": "100 Hillcrest Medical Blvd",
            "city": "Waco",
            "state": "TX",
            "country_code": "US",
            "postal_code": "767128897",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Brian Cooper Hussey
• Susan C Hustad, M.D.
• Anne M Hutchinson, M.D.
• Spencer B Hyde, DO
• Sarah Iannacone, PHARMD
• Ideal Mindset LLC
• Ihc Health Services Inc
• Ihc Health Services Inc
• Ihc Health Services Inc
• Ihc Health Services Inc

• All providers in Ogden, UT
• Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 13, 2022; 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.