Basic Information
| Provider Information | |||||||||
| NPI: | 1619920311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOENCH | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5009 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 W 69TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 1548 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 165027 | 01 | UCARE | OTHER | 6001200 | 05 | SD | MEDICAID | 1106195 | 05 | IA | MEDICAID | 24681 | 01 | HEALTH PARTNERS | OTHER | 92589MO | 01 | MN | MN BCBS - PLAN 91057NO | OTHER | 931451029038 | 01 | PREFERRED ONE | OTHER | 0009604 | 01 | SD | SD BCBS | OTHER | 538R5MO | 01 | MN | MN BCBS - PLAN 538R2NO | OTHER | 1548 | 01 | SD | DAKOTACARE | OTHER |