Provider Demographics
NPI:1740560580
Name:STATE OF MISSOURI
Entity Type:Organization
Organization Name:STATE OF MISSOURI
Other - Org Name:SOUTHEAST MISSOURI RESIDENTIAL SERVICES-POPLAR BLUFF PROF GRP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BOECKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-751-4055
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-0687
Mailing Address - Country:US
Mailing Address - Phone:573-751-3398
Mailing Address - Fax:573-526-4560
Practice Address - Street 1:2351 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4035
Practice Address - Country:US
Practice Address - Phone:573-840-9370
Practice Address - Fax:573-840-9373
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSOURI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-25
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty