Provider Demographics
NPI:1275576654
Name:POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Other - Org Name:PUXICO MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-215-3953
Mailing Address - Street 1:130 E HARBIN AVE
Mailing Address - Street 2:
Mailing Address - City:PUXICO
Mailing Address - State:MO
Mailing Address - Zip Code:63960-9104
Mailing Address - Country:US
Mailing Address - Phone:573-222-3556
Mailing Address - Fax:
Practice Address - Street 1:130 E HARBIN AVE
Practice Address - Street 2:
Practice Address - City:PUXICO
Practice Address - State:MO
Practice Address - Zip Code:63960-9104
Practice Address - Country:US
Practice Address - Phone:573-222-3556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO598145803Medicaid
263473Medicare Oscar/Certification