Provider Demographics
NPI:1386998318
Name:BLACK RIVER MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:BLACK RIVER MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURCHAM
Authorized Official - Suffix:SR
Authorized Official - Credentials:MBA, RRT
Authorized Official - Phone:573-727-9125
Mailing Address - Street 1:217 PHYSICIANS PARK DRIVE
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:573-727-9125
Mailing Address - Fax:573-686-1245
Practice Address - Street 1:225 PHYSICIANS PARK
Practice Address - Street 2:SUITE 204
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-785-4601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK RIVER COMMUNITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-29
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty