Active NPI
Vicksburg Clinic LLC
Doing business as River Region Rural Health - SC
- Rural Health Clinic/Center
- Vicksburg, MS
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Rural Health Clinic/Center
- Legal business name
- VICKSBURG CLINIC LLC
- Doing business as
- River Region Rural Health - SC
- Practice address
- 2200 Highway 61 N
Vicksburg, MS 39183-8246 - Phone
- (601) 883-3300
- Fax
- (601) 883-3302
- NPI assigned
- Jul 20, 2009
- Last updated
- Nov 5, 2024
- Organization subpart
- Yes
- Parent organization
- VICKSBURG CLINIC LLC
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Kristy Music
- Title
- Director Provider Enrollment
- Phone
- (877) 892-9815
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | MS | Primary |
Addresses
Primary practice location
2200 Highway 61 N
Vicksburg, MS 39183-8246
Mailing address
PO Box 689022
Franklin, TN 37068-9022
Phone (615) 778-8071
Other names 1
- River Region Rural Health - SC
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MS
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20090903000378 | MS | Part A Provider - Rural Health Clinic | 5890696330 | Practice locations: Vicksburg, MS |
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1861622268. Details of each certification follow.
Rural health clinic certification: CCN 253817
- Legal name
- VICKSBURG CLINIC LLC
- Doing business as
- RIVER REGION RURAL HEALTH-SC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jan 29, 2010
- Last certification
- Sep 26, 2023
- Ownership / control type
- 2B
- Organization structure
- LLC
- Incorporated
- Oct 26, 1998 in DE
- Enrollment address
- 2200 Highway 61 N
Vicksburg, MS 39183-8246
Other NPIs with the same Medicare PAC ID 3
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
-
dba River Region Rural Health - MOB1
- Rural Health Clinic/Center
- Vicksburg, MS
- NPI 1790915395
5890696330
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D2096458 | River Region Rural Health System | Certificate of waiver | May 25, 2027 |
National Provider Directory
National Provider Directory- Tax ID family
- Vicksburg Clinic
- Part of
- Vicksburg Clinic
Other organizations with this tax ID 5
Organizations that report the same tax identification number in the National Provider Directory.
-
- Durable Medical Equipment & Medical Supplies
- Vicksburg, MS
- NPI 1154532257
-
- Rural Health Clinic/Center
- Vicksburg, MS
- NPI 1174494975
-
dba One Medical Plaza - RHC
- Rural Health Clinic/Center
- Vicksburg, MS
- NPI 1619355203
-
dba River Region Rural Health - MOB1
- Rural Health Clinic/Center
- Vicksburg, MS
- NPI 1790915395
-
- Surgery Physician
- Vidalia, LA
- NPI 1629279054
Ownership & related parties
All disclosed owners & managing parties 16
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Kevin J Hammons | Corporate Officer | Feb 27, 2012 | |
| Corporate Director | Jan 6, 2020 | ||
| Nathaniel K Summar | Corporate Officer | Jul 15, 2017 | 100% |
| Justin D Pitt | Corporate Officer | Mar 1, 2022 | |
| Corporate Director | Mar 1, 2022 | ||
| William Bradley Cash | Corporate Officer | Mar 1, 2022 | |
| Corporate Director | Mar 1, 2022 | ||
| Hma-Tri Holdings LLC | 5% Or Greater Indirect Ownership Interest | Jan 1, 2020 | |
| Community Health Systems Inc | 5% Or Greater Indirect Ownership Interest | Sep 1, 2009 | |
| Jason Kevin Johnson | Corporate Officer | Jan 6, 2020 | 100% |
| Roman Gabriel Ottinger | Corporate Officer | Jan 6, 2020 | 100% |
| Paula Durham | W-2 Managing Employee | Aug 24, 2023 | |
| Kristina Music | Corporate Director | Aug 22, 2022 | |
| Triad Holdings V LLC | 5% Or Greater Indirect Ownership Interest | Sep 1, 2009 | |
| Triad Healthcare LLC | 5% Or Greater Indirect Ownership Interest | Sep 1, 2009 | |
| Tennyson Holdings LLC | 5% Or Greater Indirect Ownership Interest | Sep 1, 2009 | |
| River Region Medical Corp | 5% Or Greater Direct Ownership Interest | Sep 1, 2009 | |
| Christopher G Cobb | Corporate Officer | Apr 26, 2013 | |
| CHS Community Health Systems Inc | 5% Or Greater Indirect Ownership Interest | Sep 1, 2009 |
Facilities with the same owner 120
Facilities that share an organizational owner with 5% or greater ownership or operational control.
-
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- Brandon, MS
- NPI 1205882669
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba Merit Health Rankin
- Psychiatric Hospital Unit
- Brandon, MS
- NPI 1427098391
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba Merit Health Central
- General Acute Care Hospital
- Jackson, MS
- NPI 1033163092
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba Merit Health Natchez
- Rehabilitation Hospital Unit
- Natchez, MS
- NPI 1083013478
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba Merit Health Natchez
- General Acute Care Hospital
- Natchez, MS
- NPI 1164821559
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba Merit Health Natchez
- Medicare Defined Swing Bed Hospital Unit
- Natchez, MS
- NPI 1457979908
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba Merit Health River Oaks
- General Acute Care Hospital
- Flowood, MS
- NPI 1396792032
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba Merit Health Women's Hospital
- Women's Hospital
- Jackson, MS
- NPI 1285681841
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC
-
dba River Region Rural Health - MOB1
- Rural Health Clinic/Center
- Vicksburg, MS
- NPI 1790915395
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC, River Region Medical Corp, Tennyson Holdings LLC, Triad Healthcare LLC, Triad Holdings V LLC
-
dba Merit Health River Region
- General Acute Care Hospital
- Vicksburg, MS
- NPI 1215981303
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC, River Region Medical Corp, Tennyson Holdings LLC, Triad Healthcare LLC, Triad Holdings V LLC
-
dba Merit Health River Region West
- Psychiatric Hospital Unit
- Vicksburg, MS
- NPI 1740228881
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC, River Region Medical Corp, Tennyson Holdings LLC, Triad Healthcare LLC, Triad Holdings V LLC
-
dba Merit Health Wesley
- Psychiatric Hospital Unit
- Hattiesburg, MS
- NPI 1053776591
CHS Community Health Systems Inc, Community Health Systems Inc, Hma-Tri Holdings LLC, Tennyson Holdings LLC, Triad Healthcare LLC, Triad Holdings V LLC
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1248048000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1730764800000",
"number": "1861622268",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 689022",
"city": "FRANKLIN",
"state": "TN",
"postal_code": "370689022",
"telephone_number": "615-778-8071",
"fax_number": "615-628-6877"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2200 HIGHWAY 61 N",
"city": "VICKSBURG",
"state": "MS",
"postal_code": "391838246",
"telephone_number": "601-883-3300",
"fax_number": "601-883-3302"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "VICKSBURG CLINIC LLC",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "VICKSBURG CLINIC LLC",
"enumeration_date": "2009-07-20",
"last_updated": "2024-11-05",
"certification_date": "2024-11-05",
"status": "A",
"authorized_official_last_name": "MUSIC",
"authorized_official_first_name": "KRISTY",
"authorized_official_title_or_position": "DIRECTOR PROVIDER ENROLLMENT",
"authorized_official_telephone_number": "877-892-9815"
},
"taxonomies": [
{
"code": "261QR1300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Rural Health",
"state": "MS",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "River Region Rural Health - SC",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "River Region Rural Health - SC",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Vicksburg, MS
- Vicksburg Clinic LLC (River Region Rural Health - FM)
- Vicksburg Clinic LLC (One Medical Plaza - RHC)
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC (River Region Rural Health - MOB1)
- Vicksburg Clinic LLC
- Vicksburg Community Center
- Vicksburg Convalescent, LLC (Vicksburg Convalescent Center)
- Vicksburg Emergency Physicians LLP
- Vicksburg Family Dental
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.