Provider Demographics
NPI:1558640458
Name:BAPTIST CANCER CENTER PHYSICIANS FOUNDATION, INC.
Entity Type:Organization
Organization Name:BAPTIST CANCER CENTER PHYSICIANS FOUNDATION, INC.
Other - Org Name:BAPTIST CANCER CENTER PHYSICIANS FOUNDATION, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP/CORP. SEC
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:6029 WALNUT GROVE RD STE 301
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-747-9087
Practice Address - Fax:901-747-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G709312Medicare PIN
MS302G709320Medicare PIN