Basic Information
| Provider Information | |||||||||
| NPI: | 1073119749 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRESSIVE MEDICAL MANAGEMENT OF BATESVILLE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PANOLA MEDICAL SWINGBED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 303 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386068608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625635611 | ||||||||
| FaxNumber: | 6625630155 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386068608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625635611 | ||||||||
| FaxNumber: | 6625630155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2020 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITWELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | QUENTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6627019346 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROGRESSIVE MEDICAL MANAGEMENT OF BATESVILLE LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.