Healthcare Provider Details

I. General information

NPI: 1992127088
Provider Name (Legal Business Name): BLACK RIVER MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

IV. Provider business mailing address

217 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

V. Phone/Fax

Practice location:
  • Phone: 573-727-9080
  • Fax:
Mailing address:
  • Phone: 573-727-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTY L SHAWAN
Title or Position: CEO
Credential:
Phone: 866-916-5259