Healthcare Provider Details

I. General information

NPI: 1093034266
Provider Name (Legal Business Name): ERIC NEIL-JENSEN BOYUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61
FESTUS MO
63028-4100
US

IV. Provider business mailing address

1400 US HIGHWAY 61
FESTUS MO
63028-4100
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6663
  • Fax:
Mailing address:
  • Phone: 314-251-6663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD-40619
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD-40619
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023024344
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: