Basic Information
| Provider Information | |||||||||
| NPI: | 1457881963 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POPLAR BLUFF PEDIATRIC ASSOC LL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2210 BARRON RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737852005 | ||||||||
| FaxNumber: | 5737859444 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 BARRON RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737852005 | ||||||||
| FaxNumber: | 5737859444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MOSS | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5737852005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.