Provider Demographics
NPI:1700831724
Name:POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Other - Org Name:POPLAR BLUFF REGIONAL MEDICAL CENTER
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 1:3100 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1573
Mailing Address - Country:US
Mailing Address - Phone:573-712-2546
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK GROVE RD.
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-686-5311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4852273R00000X, 282N00000X
367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No273R00000XHospital UnitsPsychiatric Unit
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO541602504Medicaid
MO61OtherBLUE CROSS
MO011602505Medicaid
MO541602504Medicaid
MO011602505Medicaid