Basic Information
| Provider Information | |||||||||
| NPI: | 1306921887 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELTA HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DELTA REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 EAST UNION ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387033246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623783783 | ||||||||
| FaxNumber: | 6627252289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 EAST UNION ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387033246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623783783 | ||||||||
| FaxNumber: | 6627252289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STACKER | ||||||||
| AuthorizedOfficialFirstName: | IRIS | ||||||||
| AuthorizedOfficialMiddleName: | Y. | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 6627252099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RHIA | ||||||||
| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 282NR1301X | 11-189 | MS | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 000020145 | 05 | MS | MEDICAID | 000020145 | 01 | MS | BLUE CROSS PROVIDER NUMBE | OTHER |