Provider Demographics
NPI:1760893259
Name:BOONE PHYSICIAN SERVICES, LLC
Entity Type:Organization
Organization Name:BOONE PHYSICIAN SERVICES, LLC
Other - Org Name:CHAS CARDIOLOGY SERVICES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-815-3269
Mailing Address - Street 1:1600 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5844
Mailing Address - Country:US
Mailing Address - Phone:573-815-6245
Mailing Address - Fax:573-815-8556
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-6245
Practice Address - Fax:573-815-8556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOONE HOSPITAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-19
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODU1604OtherRAILROAD MEDICARE
MODU1604OtherRAILROAD MEDICARE