NPIMap

Organization Active NPI

State of Missouri

Doing business as Fulton State Hospital

  • Psychiatric Hospital
  • Fulton, MO
National Provider Identifier
1104878792
Registry record updated Aug 31, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric HospitalTaxonomy code 283Q00000X
License
EXEMPT Issued in MO
Legal business name
STATE OF MISSOURI
Doing business as
Fulton State Hospital
Practice address
600 E 5TH St
Fulton, MO 65251-1753
Phone
(573) 592-4100
Fax
(573) 592-3100
NPI assigned
May 16, 2006
Last updated
Aug 31, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
STATE OF MISSOURIAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 31, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Molly Jane Boeckmann
Title
Director of Administrative Services
Phone
(573) 751-4055

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital 283Q00000X EXEMPT MO Primary

Addresses

Primary practice location

600 E 5TH St
Fulton, MO 65251-1753

Mailing address

PO Box 687
Admin-Reimbursement Section
Jefferson City, MO 65102-0687
Phone (573) 751-3398

Other names 1

  • Fulton State Hospital Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071029000586 MO Part A Provider - Hospital 1456254226 Practice locations: Fulton, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104878792. Details of each certification follow.

Hospital certification: CCN 264004

Legal name
STATE OF MISSOURI
Doing business as
FULTON STATE HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Psychiatric
Participating since
Jul 1, 1966
Last certification
Jul 17, 2003
Beds
484 (50 certified)
Ownership / control type
State
Organization structure
GovernmentNon-profit
Enrollment address
600 E 5TH St
Fulton, MO 65251-1753
Other Hospital Practice Location
Hospital subgroups
Psychiatric

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospital

Medicare Care Compare
Listed as
Center for Behavioral MedicineCCN 264004 · All quality measures
Type
Psychiatric
Ownership
Government - State
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
No

National Provider Directory

National Provider Directory
Tax ID family
Missouri Tuberculosis Lab104 organizations share this tax ID, including this one
Part of
Missouri Tuberculosis Lab

Organizations with this tax ID in the same state 17

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 17

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Molly Boeckmann Individual Corporate DirectorDirector of Admin Services Jul 1, 2020
State of Missouri Organization, Jefferson City, MO 5% Or Greater Direct Ownership Interest Jul 1, 1966 100%
Sanjv Sethi Individual W-2 Managing EmployeeMedical Director Aug 15, 2013
Gloria Gehlert Individual W-2 Managing EmployeeAccounting Specialist III Jan 9, 2015
Jennifer Bax Individual W-2 Managing EmployeeDirector of Medicaid & Reimb Jul 1, 2023
Robert Reitz Individual W-2 Managing Employee Jun 9, 2006
Andrew Atkinson Individual W-2 Managing Employee Aug 28, 2018
Debra Salmons Individual Corporate OfficerCfo Oct 16, 2022

Owners & managing parties with NPI records 11

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • State of Missouri

    dba Hawthorn Children's Psychiatric Hosptial

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1033289897

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Northwest MO Psychiatric Rehabilitation Center

    • Psychiatric Hospital
    • Saint Joseph, MO
    • NPI 1104879444

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Fulton State Hospital

    • Psychiatry Physician
    • Fulton, MO
    • NPI 1164477873

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba St. Louis Developmental Disabilities Treatment Center

    • General Practice Physician
    • Saint Charles, MO
    • NPI 1316991896

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba St Louis Forensic Treatment Center

    • Psychiatry Physician
    • Saint Louis, MO
    • NPI 1427002013

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Southeast MO Mental Health Center

    • Psychiatry Physician
    • Farmington, MO
    • NPI 1437106705

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Center for Behavioral Health

    • Psychiatry Physician
    • Kansas City, MO
    • NPI 1497709083

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba St Louis Forensic Treatment Center

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1578518239

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Bellefontaine Habilitation Center

    • Physical Medicine & Rehabilitation Physician
    • Saint Louis, MO
    • NPI 1710931167

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Center for Behavioral Medicine

    • Psychiatric Hospital
    • Kansas City, MO
    • NPI 1730134495

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Southeast MO Mental Health Center

    • Psychiatric Hospital
    • Farmington, MO
    • NPI 1861447526

    5% Or Greater Direct Ownership Interest

    CMS ownership

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Center for Behavioral MedicineKansas City, MO, CCN 264008 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
St Louis Forensic Treatment CenterSaint Louis, MO, CCN 264010 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Southeast Missouri Mental Health CenterFarmington, MO, CCN 264005 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Northwest Missouri Psychiatric Rehabilitation CenterSaint Joseph, MO, CCN 264007 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 1966
Jan 1, 1966
Hawthorn Children's Psychiatric HospitalSaint Louis, MO, CCN 264028 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1981

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • State of Missouri

    dba Hawthorn Children's Psychiatric Hosptial

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1033289897

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Northwest MO Psychiatric Rehabilitation Center

    • Psychiatric Hospital
    • Saint Joseph, MO
    • NPI 1104879444

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba St Louis Forensic Treatment Center

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1578518239

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Center for Behavioral Medicine

    • Psychiatric Hospital
    • Kansas City, MO
    • NPI 1730134495

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Southeast MO Mental Health Center

    • Psychiatric Hospital
    • Farmington, MO
    • NPI 1861447526

    5% Or Greater Direct Ownership Interest

    CMS ownership

Facilities with the same owner 5

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598832000000",
    "number": "1104878792",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 687",
            "address_2": "ADMIN-REIMBURSEMENT SECTION",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651020687",
            "telephone_number": "573-751-3398",
            "fax_number": "573-526-4560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 E 5TH ST",
            "city": "FULTON",
            "state": "MO",
            "postal_code": "652511753",
            "telephone_number": "573-592-4100",
            "fax_number": "573-592-3100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF MISSOURI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE OF MISSOURI",
        "enumeration_date": "2006-05-16",
        "last_updated": "2020-08-31",
        "certification_date": "2020-08-31",
        "status": "A",
        "authorized_official_last_name": "BOECKMANN",
        "authorized_official_first_name": "MOLLY",
        "authorized_official_middle_name": "JANE",
        "authorized_official_title_or_position": "DIRECTOR OF ADMINISTRATIVE SERVICES",
        "authorized_official_telephone_number": "573-751-4055"
    },
    "taxonomies": [
        {
            "code": "283Q00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Hospital",
            "state": "MO",
            "license": "EXEMPT",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fulton State Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Fulton State Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fulton, MO

Sources for this page

Verify at the official NPI Registry.