Provider Demographics
NPI:1295767689
Name:DELTA MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:DELTA MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-382-8126
Mailing Address - Street 1:811 HWY 65 SOUTH
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:AR
Mailing Address - Zip Code:71639
Mailing Address - Country:US
Mailing Address - Phone:870-382-4303
Mailing Address - Fax:870-382-6555
Practice Address - Street 1:811 HWY 65 SOUTH
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639
Practice Address - Country:US
Practice Address - Phone:870-382-4303
Practice Address - Fax:870-382-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4296282NC0060X
ARAR4392282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11326OtherBLUE CROSS PROVIDER NUMBE
AR102081105Medicaid
AR041326Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER