Provider Demographics
| NPI: | 1992774814 |
|---|---|
| Name: | MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC. |
| Entity type: | Organization |
| Organization Name: | MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, 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: | 601-292-4261 |
| Mailing Address - Fax: | 601-292-4262 |
| Practice Address - Street 1: | 1200 N STATE ST STE 270 |
| Practice Address - Street 2: | |
| Practice Address - City: | JACKSON |
| Practice Address - State: | MS |
| Practice Address - Zip Code: | 39202-2027 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 601-974-6246 |
| Practice Address - Fax: | 601-353-4414 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | BAPTIST MEMORIAL HEALTH CARE CORP. |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-03-14 |
| Last Update Date: | 2020-10-06 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MS | 03807380 | Medicaid | |
| MS | 09014808 | Medicaid | |
| 168390700 | Other | DOL - DOGWOOD | |
| DA0407 | Other | RR MEDICARE | |
| MS | 09014930 | Medicaid | |
| 168390703 | Other | DOL - CLINTON | |
| 168390706 | Other | DOL - GLUCK | |
| 168390707 | Other | DOL - MADISON | |
| 300002200 | Other | DOL - BAPT NEUROSURGEONS | |
| 300002201 | Other | DOL - BAPT NEUROLOGY | |
| MS | 08588008 | Medicaid | |
| 168390702 | Other | DOL - BYRAM | |
| 168390705 | Other | DOL -AIRPORT | |
| 168390709 | Other | DOL - CARDIOLOGY JACKSON | |
| MS | 01627892 | Medicaid | |
| 168390708 | Other | DOL - HOSPITALIST PROGRAM | |
| MS | 08134261 | Medicaid | |
| MS | 09152270 | Medicaid | |
| 168390701 | Other | DOL - NORTHTOWN | |
| MS | 06758598 | Medicaid | |
| 168390704 | Other | DOL - MAE | |
| MS | 09014667 | Medicaid | |
| 168390709 | Other | DOL - CARDIOLOGY JACKSON | |
| MS | ========= | Other | AETNA |
| 168390703 | Other | DOL - CLINTON | |
| 168390708 | Other | DOL - HOSPITALIST PROGRAM | |
| MS | 09014808 | Medicaid | |
| MS | 09152270 | Medicaid | |
| MS | 08134261 | Medicaid |
