Provider Demographics
NPI:1174506281
Name:DELTA HEART & VASCULAR CENTER, P.A.
Entity Type:Organization
Organization Name:DELTA HEART & VASCULAR CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MD
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-335-0183
Mailing Address - Street 1:1421 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-3247
Mailing Address - Country:US
Mailing Address - Phone:662-335-0183
Mailing Address - Fax:662-335-7184
Practice Address - Street 1:1421 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3247
Practice Address - Country:US
Practice Address - Phone:662-335-0183
Practice Address - Fax:662-335-7184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190990002Medicaid
MS9016026Medicaid
MSDA3016OtherRAILROAD MEDICARE
AR190990002Medicaid