NPIMap

Organization Active NPI

Chicot Memorial Medical Center

  • Clinic/Center
  • Lake Village, AR
National Provider Identifier
1104238179
Registry record updated Jul 9, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
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
May 27, 2014
Last updated
Jul 9, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2015

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

Authorized official

Name
Susan Vaughn
Title
Cfo
Phone
(870) 265-5351

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary

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 3

IdentifierTypeStateIssuer
04-1328OtherMEDICARE PROVIDER NUMBER
04-Z328OtherMEDICARE PROVIDER NUMBER
181080105MedicaidAR

Other names 1

  • Chicot Memorial Medical Center Womens Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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
O20101006000166 AR Part B Supplier - Clinic/Group Practice 2466576194 Receives reassigned benefits from 2 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lake Village, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104238179. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Dec 16, 2009 in AR
Enrollment address
2729 S Highway 65 82
Lake Village, AR 71653-6136

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

Other NPIs on the same Medicare enrollment 4

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Chicot Memorial Medical CenterCCN 041328 · All quality measures
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Shirley a Catalani Individual Corporate Director Apr 30, 2020
Guy Dino Sabbatini Individual Corporate Director Dec 20, 2022
Vicki Allen Individual Corporate OfficerChief Financial Officer Mar 28, 2023
W-2 Managing EmployeeChief Financial Officer Mar 28, 2023
Linda Thomas Individual Corporate Director May 1, 2010
Bill Elliott Individual Corporate Director Sep 20, 2017
Carrie H Pieroni Individual Corporate Director Sep 19, 2023
Sam Angel Individual Corporate Officer Feb 1, 2014
Corporate Director May 1, 2010
John P Burge Individual Corporate Director May 1, 2010

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 1

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.

Affiliated clinicians 37

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 37

NPI Registry JSON

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

{
    "created_epoch": "1401148800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1436400000000",
    "number": "1104238179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2729 HWY 65 & 82 S",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536136",
            "telephone_number": "870-265-5351",
            "fax_number": "870-265-2091"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2729 HWY 65 & 82 S",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536136",
            "telephone_number": "870-265-5351",
            "fax_number": "870-265-2091"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHICOT MEMORIAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-05-27",
        "last_updated": "2015-07-09",
        "status": "A",
        "authorized_official_last_name": "VAUGHN",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "870-265-5351"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PROVIDER NUMBER",
            "identifier": "04-1328",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PROVIDER NUMBER",
            "identifier": "04-Z328",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "181080105",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Chicot Memorial Medical Center Womens Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Lake Village, AR

Sources for this page

Verify at the official NPI Registry.