Basic Information
| Provider Information | |||||||||
| NPI: | 1407845472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POPLAR BLUFF MEDICAL PARTNERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737279080 | ||||||||
| FaxNumber: | 5736861245 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737279080 | ||||||||
| FaxNumber: | 5736861245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | BURCHAM | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 5737279080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | NOT REQUIRED | MO | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0206X | NOT REQUIRED | MO | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | NOT REQUIRED | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 710426909 | 05 | MO | MEDICAID |