Provider Demographics
NPI:1457676942
Name:CHICOT MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:CHICOT MEMORIAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-265-5351
Mailing Address - Street 1:2729 HWY 65 & 82 S
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-6136
Mailing Address - Country:US
Mailing Address - Phone:870-265-5351
Mailing Address - Fax:870-265-2091
Practice Address - Street 1:2729 HWY 65 & 82 S
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-6136
Practice Address - Country:US
Practice Address - Phone:870-265-5351
Practice Address - Fax:870-265-2091
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICOT MEMORIAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-29
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00578367500000X
367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182367002Medicaid
AR182367002Medicaid