NPIMap

Organization Active NPI

Chicot Memorial Medical Center

  • Emergency Medicine Physician
  • Lake Village, AR
National Provider Identifier
1902121494
Registry record updated Jun 25, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medicine PhysicianTaxonomy code 207P00000X
Legal business name
CHICOT MEMORIAL MEDICAL CENTER
Practice address
2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136
Phone
(870) 265-5351
Fax
(870) 265-2091
NPI assigned
Mar 29, 2010
Last updated
Jun 25, 2015By the provider in NPPES
Organization subpart
Yes
Parent organization
CHICOT MEMORIAL MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 25, 2015

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

Authorized official

Name
Susan Vaughn
Title
Cfo
Phone
(870) 265-5351

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X AR4386 AR
Emergency Medicine Physician 207P00000X Primary

Addresses

Primary practice location

2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136

Mailing address

2729 Hwy 65 & 82 S
Lake Village, AR 71653-6136
Phone (870) 265-5351

Other identifiers 1

IdentifierTypeStateIssuer
182738002MedicaidAR

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101006000166 AR Part B Supplier - Clinic/Group Practice 2466576194 Receives reassigned benefits from 2 practitioners
2 other NPIs on this enrollment
Practice locations: Lake Village, AR

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 2

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

National Provider Directory

National Provider Directory
Part of
Chicot Mem Med

Practitioners & affiliated clinicians

Practitioners 2

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.

NPI Registry JSON

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

{
    "created_epoch": "1269820800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1435190400000",
    "number": "1902121494",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2729 HWY 65 & 82 S",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536136",
            "telephone_number": "870-265-5351",
            "fax_number": "870-265-2091"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2729 HWY 65 & 82 S",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716536136",
            "telephone_number": "870-265-5351",
            "fax_number": "870-265-2091"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHICOT MEMORIAL MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHICOT MEMORIAL MEDICAL CENTER",
        "enumeration_date": "2010-03-29",
        "last_updated": "2015-06-25",
        "status": "A",
        "authorized_official_last_name": "VAUGHN",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "870-265-5351"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "AR",
            "license": "AR4386",
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "182738002",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Village, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.