MEDICARE: INDEPENDENT HEALTHCARE MANAGEMENT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	10830	MS
2	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1427500958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT HEALTHCARE MANAGEMENT, INC.

Provider Business Mailing Address
First Line	:	1123 HWY. 35 SOUTH
Second Line	:
City	:	FOREST
State	:	MS
Zip	:	39074
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1123 HIGHWAY 35 S STE 3
Second Line	:
City	:	FOREST
State	:	MS
Zip	:	39074-8829
Country	:	US
Telephone Number	:	601-469-4771
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN OF THE BOARD
Name	:	JOHN P LEE
Credential	:
Telephone Number	:	601-849-6440

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	05/26/2020

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