Provider Demographics
NPI:1528528874
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:Q
Authorized Official - Last Name:WHITWELL
Authorized Official - Suffix:JR
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 1:223 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2123
Practice Address - Country:US
Practice Address - Phone:662-562-4166
Practice Address - Fax:662-562-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty