Basic Information
| Provider Information | |||||||||
| NPI: | 1528528874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANOLA PHYSICIAN GROUP, LLC | ||||||||
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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: | 223 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SENATOBIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386682123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625624166 | ||||||||
| FaxNumber: | 6625624355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2019 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITWELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | Q | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6627019346 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.