Basic Information
| Provider Information | |||||||||
| NPI: | 1619648532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOONE PHYSICIAN SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 E HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652401183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736825588 | ||||||||
| FaxNumber: | 5736821539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 E HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652401183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736825588 | ||||||||
| FaxNumber: | 5736821539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2021 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | WINN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5738153269 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.