Basic Information
| Provider Information | |||||||||
| NPI: | 1760893259 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOONE PHYSICIAN SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHAS CARDIOLOGY SERVICES, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738156245 | ||||||||
| FaxNumber: | 5738158556 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738156245 | ||||||||
| FaxNumber: | 5738158556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2014 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5738153269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOONE HOSPITAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | DU1604 | 01 | MO | RAILROAD MEDICARE | OTHER |