Healthcare Provider Details

I. General information

NPI: 1518374875
Provider Name (Legal Business Name): CHOCTAW REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W CHERRY ST
ACKERMAN MS
39735-8708
US

IV. Provider business mailing address

PO BOX 719
ACKERMAN MS
39735-0719
US

V. Phone/Fax

Practice location:
  • Phone: 662-285-6235
  • Fax:
Mailing address:
  • Phone: 662-285-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01809271
Identifier TypeMEDICAID
Identifier StateMS
Identifier Issuer

VIII. Authorized Official

Name: STEVE MONTGOMERY
Title or Position: CHANCERY CLERK
Credential:
Phone: 662-285-6329