NPIMap

Organization Active NPI

Ellis Physical Therapy and Associates LLC

  • Physical Therapy Clinic/Center
  • Idaho Falls, ID
National Provider Identifier
1821628645
Registry record updated Jan 21, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
Legal business name
ELLIS PHYSICAL THERAPY AND ASSOCIATES LLC
Practice address
3100 S Woodruff Ave
Idaho Falls, ID 83404-8310
Phone
(208) 523-8879
NPI assigned
Jan 21, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 21, 2020

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

Authorized official

Name
Dr. Logan Bradley, DPTNPI 1336661321
Title
Owner
Phone
(208) 523-8879

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
Physical Therapy Clinic/Center 261QP2000X Primary

Addresses

Primary practice location

3100 S Woodruff Ave
Idaho Falls, ID 83404-8310

Mailing address

3100 S Woodruff Ave
Idaho Falls, ID 83404-8310
Phone (208) 523-8879

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200423002867 ID Part B Supplier - Physical/Occupational Therapy Group in Private Practice 0244660710 Receives reassigned benefits from 5 practitioners
Practice locations: Ammon, ID; Idaho Falls, ID

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 11

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": "1579564800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1579564800000",
    "number": "1821628645",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3100 S WOODRUFF AVE",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834048310",
            "telephone_number": "208-523-8879"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3100 S WOODRUFF AVE",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834048310",
            "telephone_number": "208-523-8879"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELLIS PHYSICAL THERAPY AND ASSOCIATES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-21",
        "last_updated": "2020-01-21",
        "certification_date": "2020-01-21",
        "status": "A",
        "authorized_official_last_name": "BRADLEY",
        "authorized_official_first_name": "LOGAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-523-8879",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DPT"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Idaho Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 21, 2020; 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.