Organization · Type 2 NPI

State of Missouri

General Practice Physician · St. Charles, MO

NPI number 1316991896 Active

Practice location

22 Marr Ln
St. Charles, MO 63303-9000

Call (314) 340-6702 Map

Fax (314) 340-6724

Mailing address

1706 E Elm St
Jefferson City, MO 65101-4130

Specialties and licenses

Taxonomy	Code	License
Pediatrics Physician	208000000X	None listed
Urology Physician	208800000X	None listed
General Practice Physician Primary	208D00000X	None listed

General Practice Physician: A physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.

3 other providers at this address

NPI record

NPI: 1316991896
Entity type: Organization (Type 2)
Issued: May 20, 2006
Last updated: Oct 20, 2020
Status: Active
Subpart: Yes of State of Missouri

Other names

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St. Louis Developmental Disabilities Treatment Center · doing business as
St. Louis Developmental Disabilities Treatment Center · doing business as

Authorized official

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

Verify this record

This page mirrors the public NPPES file. For credentialing or billing, confirm it on the official CMS NPI Registry, and check the license with the state board.

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About NPI 1316991896

State of Missouri's National Provider Identifier is 1316991896, issued on May 20, 2006. The primary taxonomy on file is General Practice Physician (208D00000X), and the practice location is in St. Charles, MO. The record was last updated on Oct 20, 2020.