Healthcare Provider Details

I. General information

NPI: 1225380108
Provider Name (Legal Business Name): POPLAR BLUFF REGIONAL MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 KATY LN
POPLAR BLUFF MO
63901-2300
US

IV. Provider business mailing address

2360 KATY LN
POPLAR BLUFF MO
63901-2300
US

V. Phone/Fax

Practice location:
  • Phone: 573-712-2546
  • Fax: 573-712-2549
Mailing address:
  • Phone: 573-712-2546
  • Fax: 573-712-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAULA LALOR
Title or Position: DIRECTOR/DELEGATED OFFICIAL
Credential:
Phone: 629-215-3953