Provider Demographics
NPI:1396798237
Name:STATE OF MISSOURI
Entity type:Organization
Organization Name:STATE OF MISSOURI
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1706 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-4130
Mailing Address - Country:US
Mailing Address - Phone:573-751-3398
Mailing Address - Fax:573-526-4560
Practice Address - Street 1:1301 INDUSTRIAL PKWY E
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-6263
Practice Address - Country:US
Practice Address - Phone:417-876-1002
Practice Address - Fax:417-876-1004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSOURI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501499909Medicaid
MOCN7731Medicare PIN
MO990001400Medicare PIN