Provider Demographics
NPI:1083764542
Name:DELTA HEALTH SYSTEM
Entity Type:Organization
Organization Name:DELTA HEALTH SYSTEM
Other - Org Name:DELTA HEALTH PROVIDER BASED CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:STACKER
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:662-725-2099
Mailing Address - Street 1:PO BOX 5247
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-5247
Mailing Address - Country:US
Mailing Address - Phone:662-378-3783
Mailing Address - Fax:662-725-2289
Practice Address - Street 1:1400 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3246
Practice Address - Country:US
Practice Address - Phone:662-378-3783
Practice Address - Fax:662-725-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03357524Medicaid
MSC00122Medicare ID - Type UnspecifiedPART B
MS03357524Medicaid