Healthcare Provider Details

I. General information

NPI: 1104963354
Provider Name (Legal Business Name): POPLAR BLUFF CANCER & RADIATION SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3396
US

IV. Provider business mailing address

PO BOX 958262
SAINT LOUIS MO
63195-8262
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5300
  • Fax:
Mailing address:
  • Phone: 636-207-0537
  • Fax: 636-207-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUBHASH GUJARATI
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 573-686-5300