Provider Demographics
NPI:1386725513
Name:DELTA CARDIOVASCULAR CENTER, PC
Entity type:Organization
Organization Name:DELTA CARDIOVASCULAR CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-621-1915
Mailing Address - Street 1:520 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6732
Mailing Address - Country:US
Mailing Address - Phone:662-621-1915
Mailing Address - Fax:662-621-9022
Practice Address - Street 1:520 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6732
Practice Address - Country:US
Practice Address - Phone:662-621-1915
Practice Address - Fax:662-621-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08952038Medicaid
AR158639002Medicaid
MSC02833Medicare ID - Type Unspecified