Provider Demographics
NPI:1275676355
Name:POPLAR BLUFF PEDIATRIC ASSOC LL
Entity Type:Organization
Organization Name:POPLAR BLUFF PEDIATRIC ASSOC LL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-785-2005
Mailing Address - Street 1:2210 BARRON RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-785-2005
Mailing Address - Fax:573-785-9444
Practice Address - Street 1:2210 BARRON RD
Practice Address - Street 2:SUITE 120
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1908
Practice Address - Country:US
Practice Address - Phone:573-785-2005
Practice Address - Fax:573-785-9444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty