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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
1103T00000XPsychologist
2103TC0700XClinical Psychologist
31041C0700XClinical Social Worker
4152W00000XOptometrist
5207Q00000XFamily Medicine Physician
6207R00000XInternal Medicine Physician
7213E00000XPodiatrist
82084P0800XPsychiatry 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 : 1164477873
Entity Type Code : Organization
Provider Name (Legal Business Name) : STATE OF MISSOURI
Provider Business Mailing Address
First Line : 1706 E ELM ST
Second Line : PO BOX 687
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 : 600 E 5TH ST
Second Line :
City : FULTON
State : MO
Zip : 65251-1753
Country : US
Telephone Number : 573-592-4100
Fax Number : 573-592-3000
Authorized Official
Title or Position : DIRECTOR OF ADMINISTRATIVE SERVICES
Name : MOLLY JANE BOECKMANN
Credential :
Telephone Number : 573-751-4055
Provider Enumeration Date : 05/23/2006
Last Update Date : 08/28/2020

Similar Medicare Providers

1851916944 — BARBARA BORDE-KOUFIE PMHNP-BC
Practice Location Address:
600 E 5TH ST
FULTON, MO
65251-1753
Practice Phone: 573-592-2030
Practice Fax:
1760427983 — MOHAMMAD H MOJDEHI PH.D.
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600 E 5TH ST
FULTON, MO
65251-1753
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Practice Fax:
1104878792 — STATE OF MISSOURI
Practice Location Address:
600 E 5TH ST
FULTON, MO
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Practice Fax: 573-592-3100
1487691994 — RANDY L TELANDER PH.D.
Practice Location Address:
600 E 5TH ST
FULTON, MO
65251-1753
Practice Phone: 573-592-2623
Practice Fax:
1356389670 — PAUL STUVE PH.D.
Practice Location Address:
600 E 5TH ST
FULTON, MO
65251-1753
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Practice Fax:
1508803891 — RONDA REITZ PH.D.
Practice Location Address:
600 E 5TH ST
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65251-1753
Practice Phone: 573-592-2623
Practice Fax:

Directions to “STATE OF MISSOURI ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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