Basic Information
| Provider Information | |||||||||
| NPI: | 1730330168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POPLAR BLUFF REGIONAL MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | POPLAR BLUFF CRNA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3937 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639023937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737857500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2620 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737857500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2008 | ||||||||
| LastUpdateDate: | 03/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | EPSTEIN | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP & ACTING GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2395983131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.