Healthcare Provider Details

I. General information

NPI: 1386725513
Provider Name (Legal Business Name): DELTA CARDIOVASCULAR CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MEDICAL DR
CLARKSDALE MS
38614-6732
US

IV. Provider business mailing address

520 MEDICAL DR
CLARKSDALE MS
38614-6732
US

V. Phone/Fax

Practice location:
  • Phone: 662-621-1915
  • Fax: 662-621-9022
Mailing address:
  • Phone: 662-621-1915
  • Fax: 662-621-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16396
License Number StateMS

VIII. Authorized Official

Name: ROGER D WEINER
Title or Position: CEO/PRESIDENT
Credential: MD
Phone: 662-621-1915