Healthcare Provider Details

I. General information

NPI: 1649546342
Provider Name (Legal Business Name): BAPTIST MEDICAL CENTER-LEAKE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17509 HIGHWAY 21
WALNUT GROVE MS
39189-6505
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 601-267-1320
  • Fax:
Mailing address:
  • Phone: 601-267-1320
  • Fax: 601-267-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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