MEDICARE: POPLAR BLUFF REGIONAL MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	273R00000X	Psychiatric Hospital Unit	4852	MO
2	367500000X	Certified Registered Nurse Anesthetist
3	282N00000X	General Acute Care Hospital	4852	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	61	OTHER	MO	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700831724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POPLAR BLUFF REGIONAL MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	3100 OAK GROVE RD
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-1573
Country	:	US
Telephone Number	:	573-712-2546
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 OAK GROVE RD.
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901
Country	:	US
Telephone Number	:	573-686-5311
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/DELEGATED OFFICIAL
Name	:	PAULA LALOR
Credential	:
Telephone Number	:	629-215-3953

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	04/20/2021

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