Healthcare Provider Details

I. General information

NPI: 1295699486
Provider Name (Legal Business Name): BOONE PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E BROADWAY STE 200
COLUMBIA MO
65201-8023
US

IV. Provider business mailing address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-8000
  • Fax:
Mailing address:
  • Phone: 573-815-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: EDWARD JAMES CLAYTON JR.
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 573-815-3072