Basic Information
| Provider Information | |||||||||
| NPI: | 1679625511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST MEMORIAL HOSPITAL- DESOTO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 N HUMPHREYS BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623494000 | ||||||||
| FaxNumber: | 3342441830 | ||||||||
| Practice Location | |||||||||
| Address1: | 7601 SOUTHCREST PKWY | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386714739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623494000 | ||||||||
| FaxNumber: | 3342441830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | DUCKETT | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP/ CLO | ||||||||
| AuthorizedOfficialTelephone: | 9012275233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST MEMORIAL HEALTH CARE CORP. | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 09013581 | 05 | MS | MEDICAID |