Basic Information
| Provider Information | |||||||||
| NPI: | 1649441569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST MEMORIAL HEALTH SERVICES INC OF MISSISSIPPI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 N HUMPHREYS BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012277463 | ||||||||
| FaxNumber: | 9012275699 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 STARLYN AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386522428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625345891 | ||||||||
| FaxNumber: | 6625345970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2008 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | POUNDS | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9012277463 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST MEMORIAL HEALTH SERVICES INC OF MISSISSIPPI | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00807053 | 05 | MS | MEDICAID |