Provider Demographics
NPI:1316991896
Name:STATE OF MISSOURI
Entity type:Organization
Organization Name:STATE OF MISSOURI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BOECKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-751-4055
Mailing Address - Street 1:1706 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-4130
Mailing Address - Country:US
Mailing Address - Phone:573-751-3398
Mailing Address - Fax:573-526-4560
Practice Address - Street 1:22 MARR LN
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-9000
Practice Address - Country:US
Practice Address - Phone:314-340-6702
Practice Address - Fax:314-340-6724
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSOURI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501500011Medicaid
MODA2122Medicare ID - Type UnspecifiedRAILROAD PROF GROUP
MO501500011Medicaid