Black River Community Medical Center

Primary specialty

Rural Acute Care HospitalTaxonomy code 282NR1301X

Legal business name

BLACK RIVER COMMUNITY MEDICAL CENTER

Doing business as

Black River Medical Center

Practice address

217 Physicians Park Drive
Poplar Bluff, MO 63901-3956

Phone

(573) 727-9080

Fax

(573) 778-0265

NPI assigned

Oct 26, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Christy L Shawan

Title

Ceo

Phone

(573) 609-2495

Specialties & licenses 1

Addresses

Other names 1

• Black River Medical Center Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Hospital certification: CCN 260227

Legal name

BLACK RIVER COMMUNITY MEDICAL CENTER

Certification status

Terminated Voluntary: merger or closure, Aug 12, 2019

Provider type (POS)

Hospital – Short-term

Participating since

Aug 31, 2012

Last certification

Aug 31, 2012

Beds

3

Ownership / control type

Private (not for profit)

Facility address

217 Physicians Park Drive
Poplar Bluff, MO 63901

Locations

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

• Black River Medical Group, LLC

  • Surgery Physician
  • Poplar Bluff, MO
  • NPI 1386998318
  NPPES parent name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1319587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447804800000",
    "number": "1548546138",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "217 PHYSICIANS PARK DRIVE",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639013956",
            "telephone_number": "573-727-9080",
            "fax_number": "573-778-0265"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "217 PHYSICIANS PARK DRIVE",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639013956",
            "telephone_number": "573-727-9080",
            "fax_number": "573-778-0265"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACK RIVER COMMUNITY MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-26",
        "last_updated": "2015-11-18",
        "status": "A",
        "authorized_official_last_name": "SHAWAN",
        "authorized_official_first_name": "CHRISTY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "573-609-2495",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "282NR1301X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Rural",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Black River Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Amanda Bishop, LPN
• Douglas R Bishop
• Lisa Diane Bishop
• Bizzee Kidz Therapy, LLC
• Black River Ambulatory Surgery Center, LLC
• Black River Healthcare, Inc.
• Black River Medical Center
• Black River Medical Group, LLC
• Amy Denise Blackburn, MCD, CFY-SLP
• Malarie Blackwell, PHARMD

• Rural Acute Care Hospital in Poplar Bluff, MO
• Providers in Poplar Bluff, MO by specialty
• Rural Acute Care Hospital in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.