Provider Demographics
NPI:1578527172
Name:BAPTIST MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BAPTIST MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
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:
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-226-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST MEMORIAL HEALTH CARE CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-12
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
TN00000104282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0440048Medicaid
TN12503Medicaid
AR82178OtherBC OF AR PROVIDER NUMBER
MS300020021OtherBC OF MS PROVIDER NUMBER
TN56540OtherBC OF TN PROVIDER NUMBER
AR107093105Medicaid
MOBA012097606Medicaid
MS00020374Medicaid
AR82178OtherBC OF AR PROVIDER NUMBER
TN12503Medicaid