Aaron E. Henry Community Health Services Center, Inc
Organization Active NPI Pediatrics Physician · Clarksdale, MS
NPI 1134868672 · NPPES record last updated Jun 2, 2022
Key facts
- NPI
- 1134868672
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pediatrics Physician 208000000X
- Legal business name
- AARON E. HENRY COMMUNITY HEALTH SERVICES CENTER, INC
- Practice address
- 2245 N State St
Clarksdale, MS 38614-6102 - Phone
- (662) 624-4292
- Fax
- (662) 624-4354
- NPI assigned
- Jun 2, 2022
- Organization subpart
- Yes
- Parent organization (as reported)
- AARON E. HENRY COMMUNITY HEALTH SERVICES CENTER, INC
Authorized official
- Name
- Candace L Fondren
- Title
- Revenue Cycle Manager
- Phone
- (662) 624-4292
Other NPIs with the same Medicare PAC ID 5
Corporate family (same tax ID) 17
Practitioners 36
-
Odilichi Ezenwanne, M.D.
-
Khalilah C George, FNP
-
Undra L Haggan, NURSE PRACTITIONER
-
Brittany Kelly Harris, NP-C
-
Sheon H Mendoza, M.D.
-
Ariel Powell, NP
-
Bridgette Rockette, FNP
-
Sidney Maurice Wilson, O.D.
-
David Lee Webber I, D.O.
-
Johnnie Cummings, M.D.
-
Anthony Newson, FNP
-
Mary Burnett, FNP
-
Erma Jean Hawkins, NURSE PRACTITIONER
-
Tiffany Newell, NP
-
Grady Devar Watt, DDS
-
Carolyn D Womack, LCSW
-
Linda D Wright, RNC
-
Tara Davis, F.N.P.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D0678162 | Children'S Clinic, the | Certificate of waiver | Jul 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Federally qualified health center certification: CCN 251134
- Legal name
- AARON E HENRY COMMUNITY HEALTH
- Doing business as
- CHILDREN'S CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 6, 2022
- Last certification
- Sep 6, 2022
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 10, 1982 in MS
- Enrollment address
- 2245 N State St
Clarksdale, MS 38614-6102
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| Aurelia Jones-Taylor |
5% Or Greater Direct Ownership Interest |
Jun 5, 1989 | 5% |
| W-2 Managing Employee |
Jun 8, 1989 | 5% | |
| Josephine Rhymes |
5% Or Greater Direct Ownership Interest |
Jan 12, 1994 | 5% |
| Robert Jackson |
5% Or Greater Direct Ownership Interest |
May 11, 2004 | 5% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20221109001009 | MS | Part a Provider - Federally Qualified Health Center (FQHC) | 1153230560 | Practice locations: Clarksdale, MS |
National Provider Directory
- Tax ID family
- Aaron E Henry Community Health
- Part of
- Aaron E Henry Community Health
Locations
1040 Desoto Ave
Clarksdale, MS 38614
Phone (601) 624-2504
2245 N State St
Clarksdale, MS 38614
Phone (662) 627-4131
643 W Service Dr
Coldwater, MS 38618
Phone (662) 233-5200
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | Yes |
Addresses
Primary practice location
2245 N State St
Clarksdale, MS 38614-6102
Mailing address
PO Box 1216
Clarksdale, MS 38614-1216
Phone (662) 624-4292
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 09010039 | Medicaid | MS |
Other names
- The Childrens Clinic
Other providers in Clarksdale, MS
- A Healthy You Medical Clinic, 'L.L.C.'
- Aaron E Henry Community Health
- Aaron E Henry Community Health
- Aaron E Henry Community Health
- Aaron E. Henry Community Health
- Aaron E. Henry Community Health Services Center, Inc
- Aaron E. Henry Community Health Services Center, Inc
- Aaron E. Henry Community Health Services Center, Inc
- Aaron E. Henry Community Health Services Center, Inc
- Aaron E. Henry Community Health Services Center, Inc
All providers in Clarksdale, MS · Pediatrics Physician in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 2, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.