NPIMap

Organization Active NPI

Mallory Community Health

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

  • Federally Qualified Health Center (FQHC)
  • Greenwood, MS
National Provider Identifier
1053649749
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
Doing business as
Dr. Arenia C. Mallory Community Health Center, Inc.
Practice address
201 East Washington Street
Greenwood, MS 38930
Phone
(662) 453-4522
Fax
(662) 453-4518
NPI assigned
Nov 18, 2009
Last updated
Aug 29, 2024By the provider in NPPES
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

201 East Washington Street
Greenwood, MS 38930

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
03357572MedicaidMS

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
O20140915001755 MS Part A Provider - Federally Qualified Health Center (FQHC) 9739074501 Practice locations: Greenwood, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053649749. Details of each certification follow.

Federally qualified health center certification: CCN 251021

Legal name
MALLORY COMMUNITY HEALTH
Doing business as
DR ARENIA C MALLORY COMMUNITY HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 2013
Last certification
Oct 1, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 26, 1993 in MS
Enrollment address
201 East Washington Street
Mallory Community Health Center
Greenwood, MS 38935-0946

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

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
Charles Washington Individual Operational/Managerial ControlBoard Member Sep 16, 2009 10%
Mary Kimes Individual Operational/Managerial ControlBoard Treasurer Apr 1, 1995 15%
Alice Scott Individual Operational/Managerial ControlBoard Vice Chairperson Apr 1, 2005 15%
Robin McCrory Individual Operational/Managerial ControlBoard Member Jan 19, 2012 10%
Clyde Rozell Chapman Individual Corporate Director Jul 2, 2015
Operational/Managerial Control Jul 2, 2015

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Mallory Community Health CenterCanton, MS, CCN 251878 Federally qualified health center Operational/Managerial Control Mar 6, 2007
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 2

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

  • Mallory Community Health

    dba Dr. Arenia C. Mallory Community Health Center, Inc.

    • Federally Qualified Health Center (FQHC)
    • Canton, MS
    • NPI 1013034636

    Operational/Managerial Control

    CMS ownership
  • Mallory Community Health

    dba Dr. Arenia C. Mallory Community Health Center, Inc.

    • Federally Qualified Health Center (FQHC)
    • Lexington, MS
    • NPI 1740624881

    5% Or Greater Security Interest

    CMS ownership

NPI Registry JSON

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

{
    "created_epoch": "1258502400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724889600000",
    "number": "1053649749",
    "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": "201 EAST WASHINGTON STREET",
            "city": "GREENWOOD",
            "state": "MS",
            "postal_code": "38930",
            "telephone_number": "662-453-4522",
            "fax_number": "662-453-4518"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MALLORY COMMUNITY HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-18",
        "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": "03357572",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dr. Arenia C. Mallory Community Health Center, Inc.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Greenwood, MS

Sources for this page

Verify at the official NPI Registry.