Provider Demographics
NPI:1548206543
Name:DELTA DIAGNOSTIC & THERAPEUTIC RAD
Entity Type:Organization
Organization Name:DELTA DIAGNOSTIC & THERAPEUTIC RAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-850-6053
Mailing Address - Street 1:316 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601-4217
Mailing Address - Country:US
Mailing Address - Phone:870-850-6053
Mailing Address - Fax:870-850-6482
Practice Address - Street 1:316 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-4217
Practice Address - Country:US
Practice Address - Phone:870-850-6053
Practice Address - Fax:870-850-6482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR23332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155956002Medicaid
AR5C647OtherAR BLUE CROSS BLUE SHIELD
AR770218402OtherBREAST CARE
ARDC3930OtherPALMETTO GBA GROUP
AR5C647Medicare PIN