Provider Demographics
NPI:1720059249
Name:DELTA REGIONAL ANESTHESIOLOGY GROUP
Entity type:Organization
Organization Name:DELTA REGIONAL ANESTHESIOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN RECRUITMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOWLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-334-2005
Mailing Address - Street 1:PO BOX 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5019
Mailing Address - Country:US
Mailing Address - Phone:800-232-5703
Mailing Address - Fax:
Practice Address - Street 1:1400 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3246
Practice Address - Country:US
Practice Address - Phone:662-334-2005
Practice Address - Fax:662-334-2189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DELTA REGIONAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-01
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03269Medicare PIN