Provider Demographics
NPI:1649546342
Name:BAPTIST MEDICAL CENTER-LEAKE, INC
Entity type:Organization
Organization Name:BAPTIST MEDICAL CENTER-LEAKE, INC
Other - Org Name:<UNAVAIL>
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:601-267-1320
Mailing Address - Fax:601-267-1469
Practice Address - Street 1:242 THAGGARD RD
Practice Address - Street 2:
Practice Address - City:MADDEN
Practice Address - State:MS
Practice Address - Zip Code:39109
Practice Address - Country:US
Practice Address - Phone:601-267-1320
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:2012-03-27
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty