1306940739 NPI number — DR. KEVIN R MOORE MD

Table of content: DR. KEVIN R MOORE MD (NPI 1306940739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306940739 NPI number — DR. KEVIN R MOORE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
KEVIN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1306940739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
869 E 4500 S
Provider Second Line Business Mailing Address:
PMB 511
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-3049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-487-0451
Provider Business Mailing Address Fax Number:
801-487-2467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N MEDICAL DR
Provider Second Line Business Practice Location Address:
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:
84113-1103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-662-1900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2006

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: 2085P0229X , with the licence number:  273877-1205 , 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: 870355724KRM . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 35834 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 83716 . This is a "PUBLIC EMPLOYEES HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107007661103 . This is a "SELECTHEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1600788 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 8550895 . This is a "AETNA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000027099 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 7541 . This is a "UUHN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 8061904 . This is a "CIGNA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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