Basic Information
Provider Information
NPI: 1619923661
EntityType: 2
ReplacementNPI:  
OrganizationName: DELTA ENDOSCOPY CENTER, P.C.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 9140 HIGHWAY 51 N
Address2:  
City: SOUTHAVEN
State: MS
PostalCode: 386711233
CountryCode: US
TelephoneNumber: 6622808222
FaxNumber: 6622805541
Practice Location
Address1: 9140 HIGHWAY 51 N
Address2:  
City: SOUTHAVEN
State: MS
PostalCode: 386711233
CountryCode: US
TelephoneNumber: 6622808222
FaxNumber: 6622805541
Other Information
ProviderEnumerationDate: 05/25/2006
LastUpdateDate: 04/20/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DUNCAN
AuthorizedOfficialFirstName: ULRIC
AuthorizedOfficialMiddleName: D.
AuthorizedOfficialTitleorPosition: GASTROENTEROLOGIST
AuthorizedOfficialTelephone: 6622808222
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QA1903X15684MSY Ambulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical

ID Information
IDTypeStateIssuerDescription
0077035605MS MEDICAID
313445301MSBLUECROSS BLUESHIELD TNOTHER
428702201MSTENNESEE MEDICAIDOTHER


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