Provider Demographics
NPI:1033589163
Name:PONTOTOC HEALTH PROVIDERS
Entity Type:Organization
Organization Name:PONTOTOC HEALTH PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:REPPERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-3978
Mailing Address - Street 1:176 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-3311
Mailing Address - Country:US
Mailing Address - Phone:662-489-5510
Mailing Address - Fax:
Practice Address - Street 1:450 E PRESIDENT AVE
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5599
Practice Address - Country:US
Practice Address - Phone:662-377-4685
Practice Address - Fax:662-377-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty