Basic Information
Provider Information | |||||||||
NPI: | 1447818026 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DELTA HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DELTA HEALTH-MEDICAL GROUP (ANESTHESIA) | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5247 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 387045247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6627252740 | ||||||||
FaxNumber: | 6627252189 | ||||||||
Practice Location | |||||||||
Address1: | 1400 E UNION ST | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 387033246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623783783 | ||||||||
FaxNumber: | 6627252189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2019 | ||||||||
LastUpdateDate: | 09/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHRISTENSEN | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6627252020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DELTA HEALTH SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 207L00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.