Provider Demographics
NPI:1982723904
Name:BAPTIST MEMORIAL HOSPITAL LAUDERDALE
Entity Type:Organization
Organization Name:BAPTIST MEMORIAL HOSPITAL LAUDERDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLALACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-221-2402
Mailing Address - Street 1:326 ASBURY AVE
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063-5577
Mailing Address - Country:US
Mailing Address - Phone:731-221-2402
Mailing Address - Fax:
Practice Address - Street 1:326 ASBURY AVE
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-5577
Practice Address - Country:US
Practice Address - Phone:731-221-2402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST MEMORIAL HOSPITAL LAUDERDALE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000088275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN044Z314Medicaid
TN9859OtherBC PROV NUMBER
TN44Z314Medicare Oscar/Certification
TN44Z314Medicare ID - Type UnspecifiedMEDICARE PROV NUMBER