Basic Information
| Provider Information | |||||||||
| NPI: | 1386011799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELTA HEALTHCARE CENTER, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1308 BRIARVILLE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371155127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158683131 | ||||||||
| FaxNumber: | 6155150205 | ||||||||
| Practice Location | |||||||||
| Address1: | 1308 BRIARVILLE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371155127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158683131 | ||||||||
| FaxNumber: | 6155150205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 11/25/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZUA | ||||||||
| AuthorizedOfficialFirstName: | MENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6158683131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q018394 | 05 | TN | MEDICAID |