Healthcare Provider Details

I. General information

NPI: 1457881963
Provider Name (Legal Business Name): POPLAR BLUFF PEDIATRIC ASSOC LL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 BARRON RD
POPLAR BLUFF MO
63901-1908
US

IV. Provider business mailing address

2210 BARRON RD
POPLAR BLUFF MO
63901-1908
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-2005
  • Fax: 573-785-9444
Mailing address:
  • Phone: 573-785-2005
  • Fax: 573-785-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY L MOSS
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-785-2005