MEDICARE: BAPTIST MEDICAL CENTER-LEAKE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548310782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAPTIST MEDICAL CENTER-LEAKE, INC

Provider Business Mailing Address
First Line	:	350 N HUMPHREYS BLVD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38120-2177
Country	:	US
Telephone Number	:	601-267-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 PARK ST
Second Line	:
City	:	WALNUT GROVE
State	:	MS
Zip	:	39189-6526
Country	:	US
Telephone Number	:	601-267-1400
Fax Number	:

Authorized Official
Title or Position	:	SR VP/CLO
Name	:	GREGORY M DUCKETT
Credential	:
Telephone Number	:	901-227-5233

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	09/30/2020

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