Provider Demographics
NPI:1255580049
Name:DELTA NEUROLOGY CLINIC, PLLC
Entity type:Organization
Organization Name:DELTA NEUROLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:M
Authorized Official - Middle Name:FASEEH
Authorized Official - Last Name:HADIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-627-2544
Mailing Address - Street 1:785 OHIO AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6217
Mailing Address - Country:US
Mailing Address - Phone:662-627-2544
Mailing Address - Fax:662-627-2052
Practice Address - Street 1:785 OHIO AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6217
Practice Address - Country:US
Practice Address - Phone:662-627-2544
Practice Address - Fax:662-627-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17427261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124811Medicaid
AR154530001Medicaid
AR154530001Medicaid