Provider Demographics
NPI:1962408187
Name:POPLAR BLUFF REGIONAL MEDICAL CENTER INC
Entity type:Organization
Organization Name:POPLAR BLUFF REGIONAL MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VP AND GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:239-594-7368
Mailing Address - Street 1:2620 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3396
Mailing Address - Country:US
Mailing Address - Phone:573-686-8144
Mailing Address - Fax:573-686-8147
Practice Address - Street 1:621 W PINE ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5042
Practice Address - Country:US
Practice Address - Phone:573-686-8144
Practice Address - Fax:573-686-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO751-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO580420008Medicaid
267151Medicare Oscar/Certification