1104963354 NPI number — POPLAR BLUFF CANCER & RADIATION SPECIALIST LLC

Table of content: (NPI 1104963354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104963354 NPI number — POPLAR BLUFF CANCER & RADIATION SPECIALIST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POPLAR BLUFF CANCER & RADIATION SPECIALIST LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
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NPI Number Information

NPI Number:
1104963354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 958262
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63195-8262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-207-0537
Provider Business Mailing Address Fax Number:
636-207-0221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 N WESTWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-3396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-5300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUJARATI
Authorized Official First Name:
SUBHASH
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
573-686-5300

Provider Taxonomy Codes

  • Taxonomy code: 2085R0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 711887000 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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