Provider Demographics
NPI:1790385417
Name:PANOLA PHYSICIAN GROUP, LLC
Entity Type:Organization
Organization Name:PANOLA PHYSICIAN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:QUENTIN
Authorized Official - Last Name:WHITWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-701-9346
Mailing Address - Street 1:303 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-8608
Mailing Address - Country:US
Mailing Address - Phone:662-563-5611
Mailing Address - Fax:662-563-0155
Practice Address - Street 1:2089 SOUTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6478
Practice Address - Country:US
Practice Address - Phone:662-407-0801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain