Provider Demographics
NPI:1275567349
Name:SAM DELK
Entity Type:Organization
Organization Name:SAM DELK
Other - Org Name:SAM DELK MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DELK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-725-0421
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-0126
Mailing Address - Country:US
Mailing Address - Phone:901-757-2345
Mailing Address - Fax:901-757-9065
Practice Address - Street 1:176 S BELLEVUE BLVD
Practice Address - Street 2:SUITE 505
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3417
Practice Address - Country:US
Practice Address - Phone:901-725-0421
Practice Address - Fax:901-278-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37329208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3003101Medicaid
AR114202001Medicaid
TN0037329OtherBLUE CROSS BLUE SHIELD
TN3003101Medicaid