Provider Demographics
NPI:1043299548
Name:BOEDEFELD, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:BOEDEFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4800 MEXICO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1666
Mailing Address - Country:US
Mailing Address - Phone:636-442-5035
Mailing Address - Fax:636-442-5036
Practice Address - Street 1:1055 BOWLES AVE STE 202
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2308
Practice Address - Country:US
Practice Address - Phone:636-386-7222
Practice Address - Fax:636-386-7810
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004009978207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207320102Medicaid
MO207320102Medicaid
MO929130681Medicare PIN