1609823889 NPI number — MARY GRETCHEN MOOERS MD

Table of content: MARY GRETCHEN MOOERS MD (NPI 1609823889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609823889 NPI number — MARY GRETCHEN MOOERS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOOERS
Provider First Name:
MARY
Provider Middle Name:
GRETCHEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609823889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 TENTH AVE
Provider Second Line Business Mailing Address:
SUITE # 160
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84103-2853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-408-5151
Provider Business Mailing Address Fax Number:
801-408-3598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 TENTH AVE
Provider Second Line Business Practice Location Address:
SUITE # 160
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84103-2853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-408-5151
Provider Business Practice Location Address Fax Number:
801-408-3598
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  173770-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9200054 . This is a "UHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 00558 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2748 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 71116 . This is a "PEHP #" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 357645 . This is a "MOLINA #" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 274 . This is a "TRICARE #" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2099000 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 224999 . This is a "ALTIUS PROVIDER #" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870623071M01 . This is a "EDUCATORS MUTUAL #" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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