Provider Demographics
NPI:1568879864
Name:CHOCTAW REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:CHOCTAW REGIONAL MEDICAL CENTER
Other - Org Name:CHOCTAW REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
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:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-0719
Mailing Address - Country:US
Mailing Address - Phone:662-285-4400
Mailing Address - Fax:
Practice Address - Street 1:8613 MS HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-8917
Practice Address - Country:US
Practice Address - Phone:662-285-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-18
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00431215Medicaid