NPIMap

Organization Active NPI

Tunica County Healthcare Authority

Doing business as Tunica Resorts Medical Clinic

  • Rural Health Clinic/Center
  • Tunica Resorts, MS
National Provider Identifier
1629164512
Registry record updated Jun 18, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
09015211 Issued in MS
Legal business name
TUNICA COUNTY HEALTHCARE AUTHORITY
Doing business as
Tunica Resorts Medical Clinic
Practice address
11273 U S Highway 61 North
Tunica Resorts, MS 38664
Phone
(662) 363-3224
Fax
(662) 363-3234
NPI assigned
Oct 5, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 18, 2018

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

Authorized official

Name
Barbara Conway
Title
Clinic Operations Officer
Phone
(662) 363-3224

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X 09015211 MS Primary

Addresses

Primary practice location

11273 U S Highway 61 North
Tunica Resorts, MS 38664

Mailing address

PO Box 789
Tunica, MS 38676-0789
Phone (662) 363-1465

Other identifiers 1

IdentifierTypeStateIssuer
09015211MedicaidMS

Other names 1

  • Tunica Resorts Medical Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20051221000245 MS Part B Supplier - Clinic/Group Practice 6608898499 Receives reassigned benefits from 14 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tunica, MS
O20170816001732 MS Part A Provider - Rural Health Clinic 6608898499 Practice locations: Robinsonville, MS

Rural health clinic certification: CCN 253934

Legal name
TUNICA COUNTY HEALTHCARE AUTHORITY
Doing business as
TUNICA RESORTS MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 8, 2017
Last certification
Nov 8, 2017
Ownership / control type
Non-profit – church related
Organization structure
OtherProprietary
Enrollment address
11273 Highway 61 N
Robinsonville, MS 38664-9705

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

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
25D0919065Tunica Resorts Medical Clinic11273 U S Highway 61 North, Robinsonville, MS 38664Certificate of waiverJun 2, 2027

National Provider Directory

National Provider Directory
Tax ID family
Tunical Medical Clinic5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

11273 Highway 61 N
#U
Robinsonville, MS 38664
Phone (662) 363-3224

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Timothy J Callaghan Individual Corporate DirectorMedical Director Jun 15, 2015 100%
W-2 Managing EmployeeMedical Director Jun 15, 2015 100%
Barbara Conway Individual Corporate OfficerClinic Operations Officer Jun 15, 2015 100%
W-2 Managing EmployeeClinic Operations Officer Jun 15, 2015 100%
Penny Harrison Individual Corporate OfficerClinic Operations Officer Jun 15, 2015 100%
W-2 Managing EmployeeClinic Operations Officer Jun 15, 2015 100%
Tunica County Healthcare Authority Organization, Tunica, MS Medical provider/supplier, For-profit 5% Or Greater Direct Ownership Interest Jan 31, 2006 100%

Owners & managing parties with NPI records 2

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
Tunica Medical ClinicTunica, MS, CCN 253933 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jan 31, 2006

Owned or controlled facilities with NPI records 1

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

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1160006400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1529280000000",
    "number": "1629164512",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 789",
            "city": "TUNICA",
            "state": "MS",
            "postal_code": "386760789",
            "telephone_number": "662-363-1465",
            "fax_number": "662-363-3215"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11273 U S HIGHWAY 61 NORTH",
            "city": "TUNICA RESORTS",
            "state": "MS",
            "postal_code": "38664",
            "telephone_number": "662-363-3224",
            "fax_number": "662-363-3234"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TUNICA COUNTY HEALTHCARE AUTHORITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-05",
        "last_updated": "2018-06-18",
        "status": "A",
        "authorized_official_last_name": "CONWAY",
        "authorized_official_first_name": "BARBARA",
        "authorized_official_title_or_position": "CLINIC OPERATIONS OFFICER",
        "authorized_official_telephone_number": "662-363-3224"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MS",
            "license": "09015211",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015211",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tunica Resorts Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Tunica Resorts Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Sources for this page

Verify at the official NPI Registry.