Provider Demographics
NPI:1467949941
Name:DELTA MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:DELTA MEDICAL FOUNDATION
Other - Org Name:CLARKSDALE FAM MED CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-326-3500
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-0289
Mailing Address - Country:US
Mailing Address - Phone:662-398-5111
Mailing Address - Fax:662-398-7123
Practice Address - Street 1:1209 LEE DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-3320
Practice Address - Country:US
Practice Address - Phone:662-326-3500
Practice Address - Fax:662-326-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty