NPIMap

Organization Active NPI

Choctaw Regional Medical Center

Doing business as Choctaw Medical Clinic of Ackerman

  • Family Medicine Physician
  • Ackerman, MS
National Provider Identifier
1235547878
Registry record updated May 28, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CHOCTAW REGIONAL MEDICAL CENTER
Doing business as
Choctaw Medical Clinic of Ackerman
Practice address
64 N Louisville St
Ackerman, MS 39735-9217
Phone
(662) 285-9050
NPI assigned
Jul 28, 2014
Last updated
May 28, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 28, 2025

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

64 N Louisville St
Ackerman, MS 39735-9217

Mailing address

8613 Ms Highway 12
Ackerman, MS 39735-8917
Phone (662) 285-9460

Other names 1

  • Choctaw Medical Clinic of Ackerman Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20141215002502 MS Part B Supplier - Clinic/Group Practice 2567682206 Receives reassigned benefits from 67 practitioners
3 other NPIs on this enrollment
Practice locations: Ackerman, MS; Louisville, MS

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
25D2017094Choctaw Medical Clinic of Ackerman64 North Louisville Street, Ackerman, MS 39735Certificate of waiverDec 2, 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.

Locations

8613 MS Highway 12
Ste B
Ackerman, MS 39735

Ownership & related parties

All facility ownership & control disclosures 4

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
Choctaw Medical ClinicAckerman, MS, CCN 258609 Rural health clinic 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 4

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

Practitioners & affiliated clinicians

Practitioners 67

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 67

NPI Registry JSON

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

{
    "created_epoch": "1406505600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748390400000",
    "number": "1235547878",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8613 MS HIGHWAY 12",
            "city": "ACKERMAN",
            "state": "MS",
            "postal_code": "397358917",
            "telephone_number": "662-285-9460"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "64 N LOUISVILLE ST",
            "city": "ACKERMAN",
            "state": "MS",
            "postal_code": "397359217",
            "telephone_number": "662-285-9050"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHOCTAW REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-07-28",
        "last_updated": "2025-05-28",
        "certification_date": "2025-05-05",
        "status": "A",
        "authorized_official_last_name": "HOLLINGSWORTH",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "ADMINISTRATOR & CREDENTIALING",
        "authorized_official_telephone_number": "662-285-9460"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Choctaw Medical Clinic of Ackerman",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Choctaw Medical Clinic of Ackerman",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ackerman, MS

Sources for this page

Verify at the official NPI Registry.