NPIMap

Organization Active NPI

State of Missouri

  • Family Medicine Physician
  • Poplar Bluff, MO
National Provider Identifier
1740560580
Registry record updated Oct 15, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
STATE OF MISSOURI
Practice address
2351 Kanell Blvd
Poplar Bluff, MO 63901-4035
Phone
(573) 840-9370
Fax
(573) 840-9373
NPI assigned
Aug 25, 2011
Organization subpart
Yes
Parent organization
STATE OF MISSOURIAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 15, 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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207P00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

2351 Kanell Blvd
Poplar Bluff, MO 63901-4035

Mailing address

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

Other names 1

  • Southeast Missouri Residential Services-Poplar Bluff Prof Grp Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040129000481 MO Part B Supplier - Clinic/Group Practice 1456254226 Receives reassigned benefits from 44 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fulton, MO; Poplar Bluff, MO; Sikeston, MO

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Southwest Missouri Psy104 organizations share this tax ID, including this one
Part of
Southwest Missouri Psy

Organizations with this tax ID in the same state 24

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

View all 24

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1314230400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602720000000",
    "number": "1740560580",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 687",
            "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": "2351 KANELL BLVD",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639014035",
            "telephone_number": "573-840-9370",
            "fax_number": "573-840-9373"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF MISSOURI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE OF MISSOURI",
        "enumeration_date": "2011-08-25",
        "last_updated": "2020-10-15",
        "certification_date": "2020-10-15",
        "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": "207P00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southeast Missouri Residential Services-Poplar Bluff Prof Grp",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southeast Missouri Residential Services-Poplar Bluff Prof Grp",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Poplar Bluff, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 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.

Verify at the official NPI Registry.