Provider Demographics
NPI:1790880813
Name:DELTA RADIOLOGY GROUP, LLC
Entity Type:Organization
Organization Name:DELTA RADIOLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-978-3246
Mailing Address - Street 1:PO BOX 4735
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4735
Mailing Address - Country:US
Mailing Address - Phone:214-978-3246
Mailing Address - Fax:214-978-6901
Practice Address - Street 1:1301 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2525
Practice Address - Country:US
Practice Address - Phone:214-978-3246
Practice Address - Fax:214-978-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOS170000Medicare ID - Type UnspecifiedNORTHWEST MO MEDICARE