Basic Information
| Provider Information | |||||||||
| NPI: | 1790385417 | ||||||||
| 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: | 2089 SOUTHRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624070801 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITWELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | QUENTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6627019346 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.