Active NPI
State of Missouri
- General Practice Physician
- Nevada, MO
National Provider Identifier
1114971702
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Physician
- Legal business name
- STATE OF MISSOURI
- Practice address
- 2323 N Ash St
Nevada, MO 64772-1054 - Phone
- (417) 667-7833
- Fax
- (417) 448-1138
- NPI assigned
- May 19, 2006
- Organization subpart
- Yes
- Parent organization
- STATE OF MISSOURI
NPPES NPI Registry
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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | |||
| General Practice Physician | 208D00000X | Primary |
Addresses
Primary practice location
2323 N Ash St
Nevada, MO 64772-1054
Mailing address
1706 E Elm St
Jefferson City, MO 65101-4130
Phone (573) 751-3398
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 501499917 | Medicaid | MO |
Other names 1
- Nevada Habilitation Center
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MO
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040609001176 | MO | Part B Supplier - Clinic/Group Practice | 1456254226 |
Receives reassigned benefits from 18 practitioners 6 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Kansas City, MO; Marshall, MO; Nevada, MO; Saint Joseph, MO; Higginsville, MO |
Other NPIs on the same Medicare enrollment 6
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
National Provider Directory
National Provider Directory- Part of
- Southwest Missouri Psy
Locations
2041 E Hunter St
Nevada, MO 64772
Phone (417) 667-7833
Practitioners & affiliated clinicians
Practitioners 2
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Neurology Physician
- Eau Claire, WI
- NPI 1629179221
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147996800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1598400000000",
"number": "1114971702",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1706 E ELM ST",
"city": "JEFFERSON CITY",
"state": "MO",
"postal_code": "651014130",
"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": "2323 N ASH ST",
"city": "NEVADA",
"state": "MO",
"postal_code": "647721054",
"telephone_number": "417-667-7833",
"fax_number": "417-448-1138"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "STATE OF MISSOURI",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "STATE OF MISSOURI",
"enumeration_date": "2006-05-19",
"last_updated": "2020-08-26",
"certification_date": "2020-08-26",
"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": "2084P0800X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": null,
"license": null,
"primary": false
},
{
"code": "208D00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "General Practice",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "501499917",
"state": "MO"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Nevada Habilitation Center",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Nevada Habilitation Center",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Nevada, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.