# STATE OF MISSOURI

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** STATE OF MISSOURI
- **Other names:** Southeast Missouri Residential Services-Sikeston Prof Grp
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1528348430
- **Legal business name:** STATE OF MISSOURI
- **Authorized official:** MOLLY JANE BOECKMANN (DIRECTOR OF ADMINISTRATIVE SERVICES)
- **Authorized official phone:** (573) 751-4055

## Contact information

- **Practice address:** 112 PLAZA DR, SIKESTON, MO 63801-5137
- **Practice address phone:** (573) 472-5300
- **Practice address fax:** (573) 472-5308
- **Mailing address:** PO BOX 687, JEFFERSON CITY, MO 65102-0687
- **Mailing address phone:** (573) 751-3398
- **Mailing address fax:** (573) 526-4560

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207P00000X | Emergency Medicine Physician | — | NULL | — |
| 207P00000X | Emergency Medicine Physician | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 08/23/2011
- **Last updated:** 10/20/2020