Basic Information
| Provider Information | |||||||||
| NPI: | 1962446054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POPLAR BLUFF REGIONAL MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | POPLAR BLUFF REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 OAK GROVE RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737857721 | ||||||||
| FaxNumber: | 5737769086 | ||||||||
| Practice Location | |||||||||
| Address1: | 2620 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737857721 | ||||||||
| FaxNumber: | 5737769086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6292153953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POPLAR BLUFF REGIONAL MEDICAL CENTER LLC | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 011602505 | 05 | MO | MEDICAID |