Provider Demographics
NPI: | 1790701134 |
---|---|
Name: | DELTA MEDICAL GROUP |
Entity Type: | Organization |
Organization Name: | DELTA MEDICAL GROUP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | IRIS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | STACKER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 662-378-3783 |
Mailing Address - Street 1: | PO BOX 1734 |
Mailing Address - Street 2: | |
Mailing Address - City: | GREENVILLE |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 38702-1734 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 662-725-2749 |
Mailing Address - Fax: | 662-725-2741 |
Practice Address - Street 1: | 1693 FAIRGROUNDS RD |
Practice Address - Street 2: | |
Practice Address - City: | GREENVILLE |
Practice Address - State: | MS |
Practice Address - Zip Code: | 38703-7810 |
Practice Address - Country: | US |
Practice Address - Phone: | 662-725-2749 |
Practice Address - Fax: | 662-725-2741 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-15 |
Last Update Date: | 2022-11-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 207UN0901X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AR | 156272002 | Medicaid | |
MS | 09015100 | Medicaid | |
AR | 156272002 | Medicaid | |
MS | 09015100 | Medicaid |