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NPI Code Detail

MEDICARE: STATE OF MISSOURI

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
1103TC0700XClinical Psychologist
2208D00000XGeneral Practice Physician
32084P0800XPsychiatry Physician

Other Identifiers

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

General Provider Information

NPI Number : 1427002013
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 : 5300 ARSENAL ST
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63139-1463
Country : US
Telephone Number : 314-644-8000
Fax Number :
Authorized Official
Title or Position : DIRECTOR OF ADMINISTRATIVE SERVICES
Name : MOLLY JANE BOECKMANN
Credential :
Telephone Number : 573-751-4055
Provider Enumeration Date : 05/19/2006
Last Update Date : 12/01/2020

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Directions to “STATE OF MISSOURI ” Practice Location

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