NPIMap

Organization Active NPI

Mallory Community Health

  • Federally Qualified Health Center (FQHC)
  • Canton, MS
National Provider Identifier
1013034636
Registry record updated Aug 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MALLORY COMMUNITY HEALTH
Practice address
276 Nissan Parkway, Building C
Suite 100
Canton, MS 39046
Phone
(601) 855-5275
Fax
(601) 859-3253
NPI assigned
Mar 26, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 29, 2024

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

Authorized official

Name
Mr. Clyde Rozell Chapman II, MD
Title
Chief Executive Officer
Phone
(662) 834-1857

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

276 Nissan Parkway, Building C
Suite 100
Canton, MS 39046

Mailing address

PO Box 479
Lexington, MS 39095-0479
Phone (662) 834-1857

Other identifiers 1

IdentifierTypeStateIssuer
09015635MedicaidMS

Other names 1

  • Dr. Arenia C. Mallory Community Health Center, Inc. Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040219000709 MS Part B Supplier - Clinic/Group Practice 9739074501 Receives reassigned benefits from 13 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lexington, MS
O20101123000478 MS Part A Provider - Federally Qualified Health Center (FQHC) 9739074501 Practice locations: Canton, MS

Federally qualified health center certification: CCN 251878

Legal name
MALLORY COMMUNITY HEALTH
Doing business as
MALLORY COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 14, 2001
Last certification
Feb 14, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 26, 1993 in MS
Enrollment address
276 Nissan Parkway
Building C Suite 100
Canton, MS 39146

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 6

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

National Provider Directory

National Provider Directory

Locations

276 Nissan Pkwy
#C
Canton, MS 39046
Phone (601) 855-5275

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Charles Washington Individual Operational/Managerial ControlManager Control Sep 16, 2009
Mary Kimes Individual Operational/Managerial ControlManager Control Apr 1, 1995
Cora D Stewart-Lowe Individual Corporate OfficerBoard Member Jul 2, 2015
Corporate Director Jul 2, 2015
Alice Scott Individual Corporate OfficerChairman of the Board Jul 2, 2015
Corporate Director Jul 2, 2015
Robin McCrory Individual Operational/Managerial Control Apr 1, 2005
Clyde Rozell Chapman Individual Corporate OfficerBoard Member Jul 2, 2015
Corporate Director Jul 2, 2015
W-2 Managing EmployeeInterim Ceo Jul 2, 2015
Mallory Community Health Organization, Lexington, MS Non-profit Operational/Managerial Control Mar 6, 2007

Owners & managing parties with NPI records 6

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Dr. Arenia C Mallory Community Health Center, IncLexington, MS, CCN 251018 Federally qualified health center 5% Or Greater Security Interest (100%) Apr 16, 2008

Owned or controlled facilities with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1174867200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724889600000",
    "number": "1013034636",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 479",
            "city": "LEXINGTON",
            "state": "MS",
            "postal_code": "390950479",
            "telephone_number": "662-834-1857",
            "fax_number": "662-834-4937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "276 NISSAN PARKWAY, BUILDING C",
            "address_2": "SUITE 100",
            "city": "CANTON",
            "state": "MS",
            "postal_code": "39046",
            "telephone_number": "601-855-5275",
            "fax_number": "601-859-3253"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MALLORY COMMUNITY HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-26",
        "last_updated": "2024-08-29",
        "certification_date": "2024-08-29",
        "status": "A",
        "authorized_official_last_name": "CHAPMAN",
        "authorized_official_first_name": "CLYDE",
        "authorized_official_middle_name": "ROZELL",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "662-834-1857",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "II",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015635",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dr. Arenia C. Mallory Community Health Center, Inc.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canton, MS

Sources for this page

Verify at the official NPI Registry.