Provider Demographics
NPI:1720585490
Name:DELTA MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:DELTA MEDICAL FOUNDATION
Other - Org Name:FAMILY MEDICAL 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:662-326-3502
Mailing Address - Fax:
Practice Address - Street 1:1024 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-1832
Practice Address - Country:US
Practice Address - Phone:662-326-3502
Practice Address - Fax:662-326-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-10
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01025806Medicaid