=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073793642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POPLAR BLUFF RADIOLOGY SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2007
-----------------------------------------------------
Last Update Date | 10/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 KANELL BLVD SUITE1
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-778-1336
-----------------------------------------------------
Fax | 573-778-1336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1618
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63902-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-778-1336
-----------------------------------------------------
Fax | 573-778-1336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY/TREASURER
-----------------------------------------------------
Name | MRS. KIMBERLY MCVEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-718-0181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | R4N69
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------