Healthcare Provider Details

I. General information

NPI: 1710931167
Provider Name (Legal Business Name): STATE OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10695 BELLEFONTAINE RD
SAINT LOUIS MO
63137-2315
US

IV. Provider business mailing address

1706 E ELM ST
JEFFERSON CITY MO
65101-4130
US

V. Phone/Fax

Practice location:
  • Phone: 314-340-6000
  • Fax: 314-340-6199
Mailing address:
  • Phone: 573-751-3398
  • Fax: 573-526-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MOLLY JANE BOECKMANN
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 573-751-4055