MEDICARE: DELTA HEART & VASCULAR CENTER, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	DA3016	OTHER	MS	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174506281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELTA HEART & VASCULAR CENTER, P.A.

Provider Business Mailing Address
First Line	:	1421 E UNION ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38703-3247
Country	:	US
Telephone Number	:	662-335-0183
Fax Number	:	662-335-7184

Provider Business Practice Location Address
First Line	:	1421 E UNION ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38703-3247
Country	:	US
Telephone Number	:	662-335-0183
Fax Number	:	662-335-7184

Authorized Official
Title or Position	:	CEO/MD
Name	:	JOHN L HERZOG
Credential	:
Telephone Number	:	662-335-0183

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	05/20/2021

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Directions to “DELTA HEART & VASCULAR CENTER, P.A. ” Practice Location

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