Healthcare Provider Details

I. General information

NPI: 1467949941
Provider Name (Legal Business Name): DELTA MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 LEE DR
CLARKSDALE MS
38614-3320
US

IV. Provider business mailing address

PO BOX 289
MARKS MS
38646-0289
US

V. Phone/Fax

Practice location:
  • Phone: 662-326-3500
  • Fax: 662-326-7077
Mailing address:
  • Phone: 662-398-5111
  • Fax: 662-398-7123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LONNIE MOORE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 662-326-3500