Healthcare Provider Details

I. General information

NPI: 1598038184
Provider Name (Legal Business Name): DELTA PHYSICIAN PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E STARLING ST
GREENVILLE MS
38701-4725
US

IV. Provider business mailing address

PO BOX 4739
GREENVILLE MS
38704-4739
US

V. Phone/Fax

Practice location:
  • Phone: 662-725-1500
  • Fax: 662-725-1515
Mailing address:
  • Phone: 662-725-2749
  • Fax: 662-725-2741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: IRIS STACKER
Title or Position: CEO
Credential:
Phone: 662-378-3783