NPIMap

Choctaw Regional Medical Center

Organization Active NPI Rural Health Clinic/Center · Ackerman, MS

NPI 1003223306 · NPPES record last updated May 3, 2022

Key facts

NPI
1003223306
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
CHOCTAW REGIONAL MEDICAL CENTER
Practice address
8613 Ms Highway 12
Ackerman, MS 39735-8917
Phone
(662) 285-4400
NPI assigned
Jul 18, 2014
Organization subpart
No

Authorized official

Name
Susan Hollingsworth Wells
Title
Administrator
Phone
(662) 285-9460

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 7

Organizations that report the same tax identification number in the National Provider Directory.

Facilities connected through Provider of Services related, parent or unit certification numbers.

Facilities with the same owner 5

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 46

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 46

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D2052354Choctaw Medical Clinic
8613 Ms Hwy 12, Ackerman, MS 39735		Provider-performed microscopyNov 5, 2026

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in MS

Rural health clinic certification: CCN 258609

Legal name
CHOCTAW REGIONAL MEDICAL CENTER
Doing business as
CHOCTAW MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 30, 2015
Last certification
Jun 30, 2015
Ownership / control type
2B
Organization structure
Corporation · Proprietary
Incorporated
Aug 1, 2014 in MS
Enrollment address
8613 Ms Highway 12
Ackerman, MS 39735-8917
Related CCNs
251334

All disclosed owners & managing parties 5

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Steve Marinelli
Individual 		Corporate Director
Ceo		 Mar 1, 2022
Operational/Managerial Control
Ceo		 Aug 1, 2020
Trilogy Healthcare Solutions LLC
Organization · Madison, MS
Management services company 		Operational/Managerial Control Aug 1, 2014
Trella Long
Individual 		W-2 Managing Employee
Him		 Aug 1, 2014
Choctaw Regional Medical Center
Organization · Ackerman, MS
For-profit 		5% Or Greater Direct Ownership Interest Aug 1, 2014 100%
Susan Hollingsworth
Individual 		Corporate Director
Clinic Administrator		 Aug 1, 2015
W-2 Managing Employee
Clinic Admin & Ins Cred		 Aug 1, 2014

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Choctaw Regional Medical Center
Ackerman, MS · CCN 251334		 Hospital Other Aug 1, 2014
Choctaw Regional Medical Center
Ackerman, MS · CCN 25Z334		 Hospital 5% Or Greater Direct Ownership Interest (100%) Aug 1, 2014
Louisville Medical Clinic
Louisville, MS · CCN 258602		 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 May 1, 2015
May 1, 2015

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20141212000454 MS Part a Provider - Rural Health Clinic 2567682206 Practice locations: Ackerman, MS
O20141215002502 MS Part B Supplier - Clinic/Group Practice 2567682206 Receives reassigned benefits from 67 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ackerman, MS; Louisville, MS

National Provider Directory

Tax ID family
Choctaw Regional Medical Center (8 organizations share this tax ID)

Interoperability endpoints

  • FHIR API: https://fhir-usa.unify.chbase.com/org/chocrmc-b09bb3d6

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X MS Yes

Addresses

Primary practice location

8613 Ms Highway 12
Ackerman, MS 39735-8917

Mailing address

8613 Ms Hwy 12 Campus Clinic Suite B
Ackerman, MS 39735-0719
Phone (662) 285-9460

Other identifiers

IdentifierTypeStateIssuer
04477821MedicaidMS

Other names

  • Choctaw Medical Clinic Doing business as

Other providers in Ackerman, MS

All providers in Ackerman, MS · Rural Health Clinic/Center in Mississippi

Sources for this page

Verify at the official NPI Registry.