Provider Demographics
NPI:1609979053
Name:PONTOTOC HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:PONTOTOC HEALTH SERVICES, INC.
Other - Org Name:PONTOTOC HOSPITAL ER PHYS
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:662-488-7640
Mailing Address - Fax:662-488-7675
Practice Address - Street 1:176 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-3311
Practice Address - Country:US
Practice Address - Phone:662-488-7640
Practice Address - Fax:662-488-7675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONTOTOC HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-07
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16-091261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9012148Medicaid