1619923661 NPI number — DELTA ENDOSCOPY CENTER, P.C.

Table of content: MARCIA ANN MENDENHALL PA (NPI 1780680405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619923661 NPI number — DELTA ENDOSCOPY CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELTA ENDOSCOPY CENTER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619923661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9140 HIGHWAY 51 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-1233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-280-8222
Provider Business Mailing Address Fax Number:
662-280-5541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9140 HIGHWAY 51 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-1233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-280-8222
Provider Business Practice Location Address Fax Number:
662-280-5541
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUNCAN
Authorized Official First Name:
ULRIC
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
GASTROENTEROLOGIST
Authorized Official Telephone Number:
662-280-8222

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  15684 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00770356 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3134453 . This is a "BLUECROSS BLUESHIELD TN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 4287022 . This is a "TENNESEE MEDICAID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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