Healthcare Provider Details

I. General information

NPI: 1528528874
Provider Name (Legal Business Name): PANOLA PHYSICIAN GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 MEDICAL CENTER DRIVE
BATESVILLE MS
38606
US

IV. Provider business mailing address

303 MEDICAL CENTER DR
BATESVILLE MS
38606-8608
US

V. Phone/Fax

Practice location:
  • Phone: 662-563-5611
  • Fax:
Mailing address:
  • Phone: 662-563-5611
  • Fax: 662-563-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY SMITH
Title or Position: ASSOCIATE CHIEF EXECUTIVE OFFICER
Credential:
Phone: 817-253-7630