Provider Demographics
NPI:1548546138
Name:BLACK RIVER COMMUNITY MEDICAL CENTER
Entity type:Organization
Organization Name:BLACK RIVER COMMUNITY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-609-2495
Mailing Address - Street 1:217 PHYSICIANS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3956
Mailing Address - Country:US
Mailing Address - Phone:573-727-9080
Mailing Address - Fax:573-778-0265
Practice Address - Street 1:217 PHYSICIANS PARK DRIVE
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-727-9080
Practice Address - Fax:573-778-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO260227Medicare Oscar/Certification