Provider Demographics
NPI:1174550115
Name:POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Entity type:Organization
Organization Name:POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-215-3953
Mailing Address - Street 1:PO BOX 200
Mailing Address - Street 2:101 S. PRAIRE
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63825-0200
Mailing Address - Country:US
Mailing Address - Phone:573-568-3838
Mailing Address - Fax:
Practice Address - Street 1:101 S. PRAIRIE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:63825-0200
Practice Address - Country:US
Practice Address - Phone:573-568-3838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO598557007Medicaid
MO598557007Medicaid