Healthcare Provider Details

I. General information

NPI: 1033155783
Provider Name (Legal Business Name): BAPTIST MEMORIAL HOSPITAL DESOTO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4739
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-4000
  • Fax:
Mailing address:
  • Phone: 901-877-6713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0300
License Number StateMS

VIII. Authorized Official

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