Provider Demographics
NPI:1891814802
Name:DELTA PHYSICIAN PRACTICES
Entity Type:Organization
Organization Name:DELTA PHYSICIAN PRACTICES
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 23998
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3998
Mailing Address - Country:US
Mailing Address - Phone:662-725-2749
Mailing Address - Fax:662-725-2741
Practice Address - Street 1:302 ARNOLD AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4711
Practice Address - Country:US
Practice Address - Phone:662-335-8919
Practice Address - Fax:662-335-2091
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DELTA PHSICIAN PRACTICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156272002Medicaid
MS09015100Medicaid