Basic Information
| Provider Information | |||||||||
| NPI: | 1285789677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELTA GASTROENTEROLOGY P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9140 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386711233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622808222 | ||||||||
| FaxNumber: | 6622805541 | ||||||||
| Practice Location | |||||||||
| Address1: | 9140 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386711233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622808222 | ||||||||
| FaxNumber: | 6622805541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | ULRIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | GASTROENTEROLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 6622808222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3050626 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 3729898 | 05 | TN | MEDICAID | 3050626 | 01 | TN | TENNCARE SELECT | OTHER | 3000117 | 01 | TN | TLC | OTHER |