Provider Demographics
NPI:1104963354
Name:POPLAR BLUFF CANCER & RADIATION SPECIALIST LLC
Entity type:Organization
Organization Name:POPLAR BLUFF CANCER & RADIATION SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUBHASH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUJARATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-686-5300
Mailing Address - Street 1:PO BOX 958262
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-8262
Mailing Address - Country:US
Mailing Address - Phone:636-207-0537
Mailing Address - Fax:636-207-0221
Practice Address - Street 1:2620 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3396
Practice Address - Country:US
Practice Address - Phone:573-686-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO711887000Medicaid
MO000014782Medicare ID - Type UnspecifiedMEDICARE CLINIC NUMBER