Provider Demographics
NPI:1346267424
Name:STATE OF MISSOURI
Entity Type:Organization
Organization Name:STATE OF MISSOURI
Other - Org Name:MO STATE PUBLIC HEALTH LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-751-7233
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:101 N. CHESTNUT ST.
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-0570
Mailing Address - Country:US
Mailing Address - Phone:573-751-3334
Mailing Address - Fax:573-526-2754
Practice Address - Street 1:101 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-4081
Practice Address - Country:US
Practice Address - Phone:573-751-3334
Practice Address - Fax:573-526-2754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO703405001Medicaid