Healthcare Provider Details

I. General information

NPI: 1760893259
Provider Name (Legal Business Name): BOONE PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

IV. Provider business mailing address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-6245
  • Fax: 573-815-8556
Mailing address:
  • Phone: 573-815-6245
  • Fax: 573-815-8556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN LEE WINN
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 573-815-3269