Provider Demographics
NPI:1073920328
Name:PONTOTOC HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:PONTOTOC HEALTH SERVICES, INC.
Other - Org Name:CHICKASAW MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
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 1:208 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-9326
Practice Address - Country:US
Practice Address - Phone:662-456-3437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-18
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16091261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251308Medicare Oscar/Certification