Provider Demographics
NPI:1659378610
Name:DELTA HEALTH CENTER INC
Entity Type:Organization
Organization Name:DELTA HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:662-741-2151
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:POST OFFICE BOX 900
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-0900
Mailing Address - Country:US
Mailing Address - Phone:662-741-2151
Mailing Address - Fax:662-741-2700
Practice Address - Street 1:702 MARTIN LUTHER KING ROAD
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762-9314
Practice Address - Country:US
Practice Address - Phone:662-741-2151
Practice Address - Fax:662-741-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2022-07-21
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-08
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013118Medicaid
MS251901Medicare Oscar/Certification
MS09013118Medicaid
MS251902Medicare Oscar/Certification