Provider Demographics
NPI:1538555347
Name:CHOCTAW REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:CHOCTAW REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLINGSWORTH WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-285-9460
Mailing Address - Street 1:8613 MS HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-8917
Mailing Address - Country:US
Mailing Address - Phone:662-285-9460
Mailing Address - Fax:
Practice Address - Street 1:14724 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-6318
Practice Address - Country:US
Practice Address - Phone:662-773-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01771892Medicaid
MS258602Medicare Oscar/Certification