NPIMap

Organization Active NPI

Southwest Mississippi Regional Medical Center

Doing business as Smrmc-Internal Medicine

  • Internal Medicine Physician
  • McComb, MS
National Provider Identifier
1689624090
Registry record updated Oct 12, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER
Doing business as
Smrmc-Internal Medicine
Practice address
300 Marion Ave
Suite C
McComb, MS 39648-2707
Phone
(601) 249-1350
Fax
(601) 249-2226
NPI assigned
May 10, 2006
Last updated
Oct 12, 2007By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2007

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

Authorized official

Name
Mr. David Sinclair
Title
Director
Phone
(601) 249-2701

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

300 Marion Ave
Suite C
McComb, MS 39648-2707

Mailing address

300 Marion Ave
Suite C
McComb, MS 39648-2707
Phone (601) 249-1350

Other identifiers 1

IdentifierTypeStateIssuer
09014058MedicaidMS

Other names 1

  • SMRMC-INTERNAL MEDICINE Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050629001212 MS Part A Provider - Rural Health Clinic 5193633907 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Monticello, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1689624090. Details of each certification follow.

Rural health clinic certification: CCN 258526

Legal name
SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER
Doing business as
LAWRENCE COUNTY FAMILY PRACTICE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 20, 2005
Last certification
Oct 18, 2018
Ownership / control type
Non-profit – church related
Organization structure
OtherProprietary
Enrollment address
1167 E Broad St
Monticello, MS 39654-7682
Related CCNs
251305

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Locations

300 Marion Ave
Ste C
McComb, MS 39648
Phone (601) 249-1350

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
City of McComb, Mississippi Organization, McComb, MS 5% Or Greater Direct Ownership Interest Oct 4, 1967 45%
Aaron P Price Individual Corporate DirectorChief Ambulatory Officer Jun 1, 2013
W-2 Managing EmployeeChief Ambulatory Officer Jun 1, 2013
Mallory Ginn Individual Corporate OfficerCfo Nov 28, 2012
Angela M Weems Individual W-2 Managing EmployeeCredentialing Officer Jun 1, 2013
Pike County Board of Supervisors Organization, Magnolia,, MS 5% Or Greater Direct Ownership Interest Oct 4, 1967 45%
Amite County, Board of Supervisors Organization, Liberty, MS 5% Or Greater Direct Ownership Interest Oct 4, 1967 10%
Charla Rowley Individual Corporate OfficerCeo Apr 17, 2014

NPI Registry JSON

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

{
    "created_epoch": "1147219200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1192147200000",
    "number": "1689624090",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 MARION AVE",
            "address_2": "SUITE C",
            "city": "MCCOMB",
            "state": "MS",
            "postal_code": "396482707",
            "telephone_number": "601-249-1350",
            "fax_number": "601-249-2226"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 MARION AVE",
            "address_2": "SUITE C",
            "city": "MCCOMB",
            "state": "MS",
            "postal_code": "396482707",
            "telephone_number": "601-249-1350",
            "fax_number": "601-249-2226"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-10",
        "last_updated": "2007-10-12",
        "status": "A",
        "authorized_official_last_name": "SINCLAIR",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "601-249-2701",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09014058",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SMRMC-INTERNAL MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in McComb, MS

Sources for this page

Verify at the official NPI Registry.