Provider Demographics
NPI:1942566195
Name:MOELLMER, EDWARD GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GREGORY
Last Name:MOELLMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-2743
Mailing Address - Country:US
Mailing Address - Phone:801-231-5503
Mailing Address - Fax:
Practice Address - Street 1:6640 KANIKSU ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7532
Practice Address - Country:US
Practice Address - Phone:208-267-3141
Practice Address - Fax:208-267-2202
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13338207P00000X, 207Q00000X
MT99946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20009760Medicare Oscar/Certification