Provider Demographics
NPI:1285867945
Name:DELTA SURGERY
Entity Type:Organization
Organization Name:DELTA SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:KH
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-382-1680
Mailing Address - Street 1:105 CARLTON DR
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:AR
Mailing Address - Zip Code:71639-2836
Mailing Address - Country:US
Mailing Address - Phone:870-382-1680
Mailing Address - Fax:
Practice Address - Street 1:811 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639-3006
Practice Address - Country:US
Practice Address - Phone:870-382-4303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57660OtherBLUE CROSS
AR102107001Medicaid
AR14161000001OtherQUAL CHOICE