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:
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Mailing Address - Street 1:802 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:BOWMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58623-4483
Mailing Address - Country:US
Mailing Address - Phone:701-523-5555
Mailing Address - Fax:701-523-7107
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:2025-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND14045207Q00000X
MT99946207Q00000X
IDM-13338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20009760Medicare Oscar/Certification