Provider Demographics
NPI:1619159126
Name:GERALD R MORESS MD PC
Entity Type:Organization
Organization Name:GERALD R MORESS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:MORESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-363-7386
Mailing Address - Street 1:SUITE 300
Mailing Address - Street 2:370 E SOUTH TEMPLE
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1256
Mailing Address - Country:US
Mailing Address - Phone:801-363-7386
Mailing Address - Fax:801-363-2431
Practice Address - Street 1:191 5TH STREET WEST
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:801-363-7386
Practice Address - Fax:801-363-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378319Medicare PIN