Basic Information
| Provider Information | |||||||||
| NPI: | 1376729442 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAPTIST MEMORIAL HOSPITAL NORTH MISSISSIPPI, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BMH NORTH MS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 350 N HUMPHREYS BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 126 HIGHWAY 51 N | ||||||||
| Address2: | P O BOPX 1429 | ||||||||
| City: | BATESVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386062347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625788402 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2008 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUCKETT | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP/ CLO | ||||||||
| AuthorizedOfficialTelephone: | 9012275233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST MEMORIAL HEALTH CARE CORP. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 6781 | MS | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 80770241 | 05 | MS | MEDICAID | 70648 | 01 | BLUE CROSS MS | OTHER |