Active NPI
Tellica Imaging, LLC
- Radiology Clinic/Center
- Boise, ID
National Provider Identifier
1760197198
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Radiology Clinic/Center
- Legal business name
- TELLICA IMAGING, LLC
- Practice address
- 8505 W Overland Rd
Boise, ID 83709-1644 - Phone
- (208) 417-5100
- Fax
- (208) 417-5105
- NPI assigned
- Jan 19, 2023
- Last updated
- Nov 20, 2023
- Organization subpart
- Yes
- Parent organization
- INTERMOUNTAIN HEALTHCARE
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mark L Vawdrey
- Title
- Cfo
- Phone
- (801) 718-1642
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Diagnostic Radiology Physician | 2085R0202X | |||
| Radiology Clinic/Center | 261QR0200X | Primary |
Addresses
Primary practice location
8505 W Overland Rd
Boise, ID 83709-1644
Mailing address
36 S State St Ste 2200
Salt Lake City, UT 84111-1470
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in UT, ID
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20231201000761 | UT | Part B Supplier - Clinic/Group Practice | 3577950765 |
Receives reassigned benefits from 117 practitioners 1 other NPI on this enrollment Practice locations: Murray, UT; Salt Lake City, UT |
| O20231209000226 | ID | Part B Supplier - Clinic/Group Practice | 3577950765 |
Receives reassigned benefits from 45 practitioners Practice locations: Boise, ID |
Other NPIs with the same Medicare PAC ID 8
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
Other NPIs on the same Medicare enrollment 1
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
National Provider Directory
National Provider Directory- Part of
- McKay Dee Hospital
Practitioners & affiliated clinicians
Practitioners 125
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.
-
- Diagnostic Radiology Physician
- Meridian, ID
- NPI 1821282492
-
- Diagnostic Radiology Physician
- Salt Lake City, UT
- NPI 1083143564
ID, Multi-Specialty
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1674086400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1700438400000",
"number": "1760197198",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "36 S STATE ST STE 2200",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841111470"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "8505 W OVERLAND RD",
"city": "BOISE",
"state": "ID",
"postal_code": "837091644",
"telephone_number": "208-417-5100",
"fax_number": "208-417-5105"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "TELLICA IMAGING, LLC",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "INTERMOUNTAIN HEALTHCARE",
"enumeration_date": "2023-01-19",
"last_updated": "2023-11-20",
"certification_date": "2023-11-20",
"status": "A",
"authorized_official_last_name": "VAWDREY",
"authorized_official_first_name": "MARK",
"authorized_official_middle_name": "L",
"authorized_official_title_or_position": "CFO",
"authorized_official_telephone_number": "801-718-1642"
},
"taxonomies": [
{
"code": "2085R0202X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Radiology, Diagnostic Radiology",
"state": null,
"license": null,
"primary": false
},
{
"code": "261QR0200X",
"taxonomy_group": "",
"desc": "Clinic/Center, Radiology",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Boise, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.