Basic Information
| Provider Information | |||||||||
| NPI: | 1578171872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELTA HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DELTA HEALTH CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5247 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387045247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623342021 | ||||||||
| FaxNumber: | 6627252189 | ||||||||
| Practice Location | |||||||||
| Address1: | 581 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386146733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626277163 | ||||||||
| FaxNumber: | 6626277150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2020 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | BROZOVICH | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE INTEGRITY | ||||||||
| AuthorizedOfficialTelephone: | 6627252292 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DELTA HEALTH SYSTEM | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
No ID Information.