Basic Information
| Provider Information | |||||||||
| NPI: | 1801805767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOENCH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2975 EXECUTIVE PKWY | ||||||||
| Address2: | 200 | ||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840439642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019901911 | ||||||||
| FaxNumber: | 8019901912 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 C ST | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841431005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939582 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207L00000X | 166534-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | TPRA07309 | 01 | UT | MOLINA | OTHER | 20835 | 01 | UT | DESERET MUTUAL | OTHER | 107005585102 | 01 | UT | IHC | OTHER | 1502954 | 01 | UT | UMWA | OTHER | 66119 | 01 | UT | PEHP | OTHER | QM0000075886 | 01 | UT | ALTIUS | OTHER | 702 | 01 | UT | HEALTHY U | OTHER | 820309 | 05 | AZ | MEDICAID |