MEDICARE: STATE OF MISSOURI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	EXEMPT	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275603920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF MISSOURI

Provider Business Mailing Address
First Line	:	1706 E ELM ST
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65101-4130
Country	:	US
Telephone Number	:	573-751-3398
Fax Number	:	573-526-4560

Provider Business Practice Location Address
First Line	:	1500 VANDIVER DR
Second Line	:	SUITE 100
City	:	COLUMBIA
State	:	MO
Zip	:	65202-3932
Country	:	US
Telephone Number	:	573-882-9835
Fax Number	:	573-884-4294

Authorized Official
Title or Position	:	DIRECTOR OF ADMINISTRATIVE SERVICES
Name	:	MOLLY JANE BOECKMANN
Credential	:
Telephone Number	:	573-751-4055

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	10/27/2020

Similar Medicare Providers

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Practice Location Address:

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1548322605 — STATE OF MISSOURI
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1053568865 — MICHAEL S. TODD D.M.D., LLC
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1861125387 — EMMA THERESE COOPER MD
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Directions to “STATE OF MISSOURI ” Practice Location

Language	Start Address	Practice Location

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