Chicot Memorial Medical Center
Organization Active NPI Rural Health Clinic/Center · Lake Village, AR
NPI 1003213281 · NPPES record last updated Apr 13, 2018
Key facts
- NPI
- 1003213281
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- CHICOT MEMORIAL MEDICAL CENTER
- Practice address
- 2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136 - Phone
- (870) 265-5351
- Fax
- (870) 265-2091
- NPI assigned
- Dec 3, 2014
- Organization subpart
- No
Authorized official
- Name
- Susan Vaughn
- Title
- Cfo
- Phone
- (870) 265-5351
Owners & managing parties with NPI records 1
-
John P. Burge, MD
Other NPIs on the same Medicare enrollment 3
Member of 1
Related certifications (CCN) 1
Practitioners 2
-
Michael Bradley Mayfield, M.D.
-
Roy Holloway, CRNA
Affiliated clinicians 37
-
Maher Alesali, MD
-
Autumn Bennett, WHNP-BC, AGPCNP-BC
-
Kendall Cox, APRN
-
Nina E Deal, FNP-C
-
Rodney M. Dixon, M.D.
-
Jamie Suzette Evans, M.D.
-
Nathan A Gladden, NP
-
Jo Anne Gregory, MD
-
Shenika Jackson-King, APRN
-
Christopher Johnson, FNP-BC
-
Douglas Kerin, MD
-
Michael Bradley Mayfield, M.D.
-
Mary Margaret Minsky, PA-C
-
Kathryn Pippin, APRN
-
Sylvette Rogers, MD
-
Keith O Schluterman, M.D.
-
Viviana Suarez, M.D.
-
Kimberly Weeks, CNP
Medicare Care Compare: Hospital
- Listed as
- Chicot Memorial Medical Center
- Type
- Critical Access Hospitals
- Ownership
- Voluntary non-profit - Private
- Medicare certification status
- Active
- Emergency services
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in AR
Hospital certification: CCN 041328
- Legal name
- CHICOT MEMORIAL MEDICAL CENTER
- Certification status
- Active
- Provider type (POS)
- Hospital – Critical access hospital
- Participating since
- Dec 1, 2005
- Last certification
- Mar 27, 2024
- Beds
- 25
- Ownership / control type
- Private (not for profit)
- Most recent change of ownership
- May 1, 2010 (1 total)
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 16, 2009 in AR
- Enrollment address
- 2729 S Highway 65 82
Lake Village, AR 71653-6136
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| Shirley a Catalani |
Corporate Director | Apr 30, 2020 | |
| Guy Dino Sabbatini |
Corporate Director | Dec 20, 2022 | |
| Vicki Allen |
Corporate Officer |
Mar 28, 2023 | |
| W-2 Managing Employee |
Mar 28, 2023 | ||
| Linda Thomas |
Corporate Director | May 1, 2010 | |
| Bill Elliott |
Corporate Director | Sep 20, 2017 | |
| Carrie H Pieroni |
Corporate Director | Sep 19, 2023 | |
| Sam Angel |
Corporate Officer | Feb 1, 2014 | |
| Corporate Director | May 1, 2010 | ||
| John P Burge |
Corporate Director | May 1, 2010 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20100901000344 | AR | Part B Supplier - Clinic/Group Practice | 2466576194 |
Receives reassigned benefits from 4 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Lake Village, AR |
| O20101005001173 | AR | Part a Provider - Critical Access Hospital | 2466576194 |
Receives reassigned benefits from 13 practitioners 3 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Lake Village, AR |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136
Mailing address
2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136
Phone (870) 265-5351
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 04-Z328 | Other | MEDICARE PROVIDER NUMBER | |
| 181080105 | Medicaid | AR | |
| 04-1328 | Other | MEDICARE PROVIDER NUMBER |
Other providers in Lake Village, AR
- Chicot County Early Childhood Center
- Chicot Memorial ER
- Chicot Memorial Hospital
- Chicot Memorial Hospital
- Chicot Memorial Hospital Anesthesia
- Chicot Memorial Medical Center
- Chicot Memorial Medical Center
- Chicot Memorial Medical Center
- Chicot Memorial Medical Center
- Chicot Memorial Medical Center
All providers in Lake Village, AR · Rural Health Clinic/Center in Arkansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 13, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.