Provider Demographics
NPI:1194861260
Name:BAPTIST MEDICAL CENTER-LEAKE, INC.
Entity Type:Organization
Organization Name:BAPTIST MEDICAL CENTER-LEAKE, INC.
Other - Org Name:BMC LEAKE CARTHAGE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP/CLO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-227-5233
Mailing Address - Street 1:350 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2177
Mailing Address - Country:US
Mailing Address - Phone:601-267-1470
Mailing Address - Fax:601-267-1469
Practice Address - Street 1:1100 HWY 16 EAST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-3809
Practice Address - Country:US
Practice Address - Phone:601-267-1470
Practice Address - Fax:601-267-1469
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST MEMORIAL HEALTH CARE CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11187261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016232Medicaid
MS09016232Medicaid
MS302G704652OtherMEDICARE PTAN