Provider Demographics
NPI:1407845472
Name:POPLAR BLUFF MEDICAL PARTNERS, LLC
Entity Type:Organization
Organization Name:POPLAR BLUFF MEDICAL PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BURCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:573-727-9080
Mailing Address - Street 1:221 PHYSICIANS PARK
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3956
Mailing Address - Country:US
Mailing Address - Phone:573-727-9080
Mailing Address - Fax:573-686-1245
Practice Address - Street 1:221 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-727-9080
Practice Address - Fax:573-686-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONOT REQUIRED261QM1200X, 261QR0200X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO710426909Medicaid
MO710426909Medicaid