MEDICARE: DELTA ASTHMA & ALLERGY

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	207K00000X	Allergy & Immunology Physician	12482	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	587763099B	OTHER	MS	BLUE CROSS OF MS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	587763099	OTHER	MS	TRICARE

General Provider Information

NPI Number	:	1841491404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELTA ASTHMA & ALLERGY

Provider Business Mailing Address
First Line	:	2335 HIGHWAY 1 S
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-8337
Country	:	US
Telephone Number	:	662-378-2762
Fax Number	:	662-378-9573

Provider Business Practice Location Address
First Line	:	2335 HIGHWAY 1 S
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-8337
Country	:	US
Telephone Number	:	662-378-2762
Fax Number	:	662-378-9573

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLENE B BROOME
Credential	:	MD
Telephone Number	:	662-378-2762

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/01/2010

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Directions to “DELTA ASTHMA & ALLERGY ” Practice Location

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