Basic Information
| Provider Information | |||||||||
| NPI: | 1497830806 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELTA HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DELTA HEALTH-THE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E UNION ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387033246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623783783 | ||||||||
| FaxNumber: | 6627252289 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387014719 | ||||||||
| 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: | Y | ||||||||
| ParentOrganizationLBN: | DELTA HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RHIA | ||||||||
| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 11-189 | MS | Y | Hospital Units | Psychiatric Unit |
No ID Information.