Healthcare Provider Details

I. General information

NPI: 1629016399
Provider Name (Legal Business Name): DELTA CONVENIENT CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 CENTRE PLAZA DR
JACKSON TN
38305-2862
US

IV. Provider business mailing address

17 CENTRE PLAZA DR
JACKSON TN
38305-2862
US

V. Phone/Fax

Practice location:
  • Phone: 731-512-0104
  • Fax: 731-512-0938
Mailing address:
  • Phone: 731-512-0104
  • Fax: 731-512-0938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIE HAGE-KORBAN
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 731-512-0104