Provider Demographics
NPI:1679354468
Name:MID-DELTA HEALTH SYSTEMS, INC.
Entity type:Organization
Organization Name:MID-DELTA HEALTH SYSTEMS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADNAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-747-8011
Mailing Address - Street 1:245 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:AR
Mailing Address - Zip Code:72029-2706
Mailing Address - Country:US
Mailing Address - Phone:870-747-8011
Mailing Address - Fax:870-747-3631
Practice Address - Street 1:1117 EASON RD
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:AR
Practice Address - Zip Code:72029-2808
Practice Address - Country:US
Practice Address - Phone:870-747-3381
Practice Address - Fax:870-747-3631
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-DELTA HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)