Healthcare Provider Details

I. General information

NPI: 1700831724
Provider Name (Legal Business Name): POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OAK GROVE RD.
POPLAR BLUFF MO
63901
US

IV. Provider business mailing address

3100 OAK GROVE RD
POPLAR BLUFF MO
63901-1573
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5311
  • Fax:
Mailing address:
  • Phone: 573-712-2546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number4852
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number4852
License Number StateMO

VIII. Authorized Official

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