Provider Demographics
NPI:1629287875
Name:MID-DELTA HEALTH SYSTEMS, INC
Entity Type:Organization
Organization Name:MID-DELTA HEALTH SYSTEMS, INC
Other - Org Name:MID-DELTA HEALTH SYSTEMS, INC. DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:AR/BILLING/CRED MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADNAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-747-3381
Mailing Address - Street 1:245 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:AR
Mailing Address - Zip Code:72029-2706
Mailing Address - Country:US
Mailing Address - Phone:870-747-3381
Mailing Address - Fax:870-747-3631
Practice Address - Street 1:245 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:AR
Practice Address - Zip Code:72029-2706
Practice Address - Country:US
Practice Address - Phone:870-747-3381
Practice Address - Fax:870-747-3631
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-DELTA HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112903631Medicaid