NPIMap

Organization Active NPI

Tellica Imaging, LLC

  • Radiology Clinic/Center
  • Boise, ID
National Provider Identifier
1760197198
Registry record updated Nov 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Radiology Clinic/CenterTaxonomy code 261QR0200X
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
Organization subpart
Yes
Parent organization
INTERMOUNTAIN HEALTHCAREAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 20, 2023

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)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 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, ID2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

National Provider Directory

National Provider Directory
Part of
Duchesne Valley Clinic

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Practitioners 125

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

View all 125

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.

Verify at the official NPI Registry.