Provider Demographics
NPI:1073793642
Name:POPLAR BLUFF RADIOLOGY SERVICES INC
Entity Type:Organization
Organization Name:POPLAR BLUFF RADIOLOGY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-718-0181
Mailing Address - Street 1:PO BOX 1618
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-1618
Mailing Address - Country:US
Mailing Address - Phone:573-778-1336
Mailing Address - Fax:573-778-1336
Practice Address - Street 1:1720 KANELL BLVD
Practice Address - Street 2:SUITE1
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4009
Practice Address - Country:US
Practice Address - Phone:573-778-1336
Practice Address - Fax:573-778-1336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4N692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013973Medicare PIN