NPIMap

Organization Active NPI

Choctaw Regional Medical Center

Doing business as Choctaw Medical Clinic

  • Rural Health Clinic/Center
  • Ackerman, MS
National Provider Identifier
1003223306
Registry record updated May 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CHOCTAW REGIONAL MEDICAL CENTER
Doing business as
Choctaw Medical Clinic
Practice address
8613 Ms Highway 12
Ackerman, MS 39735-8917
Phone
(662) 285-4400
NPI assigned
Jul 18, 2014
Last updated
May 3, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 3, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

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

Specialties & licenses 1

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

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 names 1

  • Choctaw Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003223306. Details of each certification follow.

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
CorporationProprietary
Incorporated
Aug 1, 2014 in MS
Enrollment address
8613 Ms Highway 12
Ackerman, MS 39735-8917
Related CCNs
251334

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

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 3

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

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D2052354Choctaw Medical Clinic8613 Ms Hwy 12, Ackerman, MS 39735Provider-performed microscopyNov 5, 2026

National Provider Directory

National Provider Directory
Tax ID family
Choctaw Regional Medical Center8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

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

Interoperability endpoints

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

Ownership & related parties

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 DirectorCeo Mar 1, 2022
Operational/Managerial ControlCeo 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 EmployeeHim 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 DirectorClinic Administrator Aug 1, 2015
W-2 Managing EmployeeClinic Admin & Ins Cred Aug 1, 2014

Owners & managing parties with NPI records 5

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

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

Owned or controlled facilities with NPI records 3

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

Facilities with the same owner 5

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

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1405641600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1651536000000",
    "number": "1003223306",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8613 MS HWY 12 CAMPUS CLINIC SUITE B",
            "city": "ACKERMAN",
            "state": "MS",
            "postal_code": "397350719",
            "telephone_number": "662-285-9460",
            "fax_number": "662-285-9324"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8613 MS HIGHWAY 12",
            "city": "ACKERMAN",
            "state": "MS",
            "postal_code": "397358917",
            "telephone_number": "662-285-4400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHOCTAW REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-07-18",
        "last_updated": "2022-05-03",
        "certification_date": "2022-04-20",
        "status": "A",
        "authorized_official_last_name": "HOLLINGSWORTH WELLS",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "662-285-9460"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Choctaw Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Choctaw Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ackerman, MS

Sources for this page

Verify at the official NPI Registry.