Provider Demographics
NPI:1720117286
Name:MISSISSIPPI BAPTIST MEDICAL CENTER
Entity Type:Organization
Organization Name:MISSISSIPPI BAPTIST MEDICAL CENTER
Other - Org Name:MBMC - AMBULANCE
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:
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 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-968-1362
Practice Address - Fax:601-292-4592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS196341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07984288Medicaid