Basic Information
| Provider Information | |||||||||
| NPI: | 1871731182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA MEDICAL WEIGHT MANAGEMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9215 MILLBRANCH RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386711423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622808222 | ||||||||
| FaxNumber: | 6625488054 | ||||||||
| Practice Location | |||||||||
| Address1: | 9215 MILLBRANCH RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386711423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622808222 | ||||||||
| FaxNumber: | 6622804845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 03/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | ULRIC | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9012808222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.