Provider Demographics
NPI:1447225503
Name:BAPTIST DESOTO SURGERY CENTER, LP
Entity Type:Organization
Organization Name:BAPTIST DESOTO SURGERY CENTER, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-349-0910
Mailing Address - Street 1:391 SOUTHCREST CIRCLE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4775
Mailing Address - Country:US
Mailing Address - Phone:662-349-0910
Mailing Address - Fax:662-349-0911
Practice Address - Street 1:391 SOUTHCREST CIRCLE
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4775
Practice Address - Country:US
Practice Address - Phone:662-349-0910
Practice Address - Fax:662-349-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS026261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00239288Medicaid
MS490000055Medicare ID - Type Unspecified