Basic Information
| Provider Information | |||||||||
| NPI: | 1699066746 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAPTIST MEDICAL CENTER - YAZOO, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BMC YAZOO PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 N HUMPHREYS BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202177 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 823 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | YAZOO CITY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391943233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627518289 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2011 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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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: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 19965 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.