Healthcare Provider Details

I. General information

NPI: 1356626618
Provider Name (Legal Business Name): BAPTIST MEDICAL CENTER-LEAKE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1000
  • Fax:
Mailing address:
  • Phone: 601-968-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY M DUCKETT
Title or Position: SR VP/ CLO
Credential:
Phone: 901-227-5233