Ebo MD of Poplar Bluff LLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

EBO MD OF POPLAR BLUFF LLC

Practice address

2725 N Westwood Blvd
Poplar Bluff, MO 63901-2346

Phone

(573) 686-5510

NPI assigned

Jun 22, 2021

Organization subpart

No

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

Authorized official

Name

Mr. Philip James Crocker

Title

Cfo

Phone

(573) 686-5510

Specialties & licenses 1

Addresses

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

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

{
    "created_epoch": "1624320000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1627257600000",
    "number": "1770152035",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2725 N WESTWOOD BLVD STE 14",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639012367",
            "telephone_number": "573-686-5510"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2725 N WESTWOOD BLVD",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639012346",
            "telephone_number": "573-686-5510"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EBO MD OF POPLAR BLUFF LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-06-22",
        "last_updated": "2021-07-26",
        "certification_date": "2021-07-01",
        "status": "A",
        "authorized_official_last_name": "CROCKER",
        "authorized_official_first_name": "PHILIP",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "573-686-5510",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Poplar Bluff, MO
• Providers in Poplar Bluff, MO by specialty
• Family Medicine Physician in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.