Basic Information
| Provider Information | |||||||||
| NPI: | 1992127088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK RIVER MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737279080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 217 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737279080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2014 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHAWAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8669165259 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.