Provider Demographics
NPI:1043564735
Name:DELTA SPECIALTY CLINIC PC
Entity Type:Organization
Organization Name:DELTA SPECIALTY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:662-332-8848
Mailing Address - Street 1:PO BOX 4577
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-4577
Mailing Address - Country:US
Mailing Address - Phone:662-332-8848
Mailing Address - Fax:662-332-8854
Practice Address - Street 1:930 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4111
Practice Address - Country:US
Practice Address - Phone:662-332-8848
Practice Address - Fax:662-332-8854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18512261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05828295Medicaid