Basic Information
| Provider Information | |||||||||
| NPI: | 1598884561 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA PHYSICIAN PRACTICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23998 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627252749 | ||||||||
| FaxNumber: | 6627252741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1693 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623328700 | ||||||||
| FaxNumber: | 6623323005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHREYS | ||||||||
| AuthorizedOfficialFirstName: | LELAND | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6623783783 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DELTA PHYSICIAN PRACTICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 09015100 | 05 | MS | MEDICAID | 156272002 | 05 | AR | MEDICAID |