MEDICARE: INDEPENDENT CASE 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	251C00000X	Developmentally Disabled Services Day Training Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	132608786	OTHER	AR	DDS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962547745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT CASE MANAGEMENT, INC.

Provider Business Mailing Address
First Line	:	1525 MERRILL DRIVE
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-1821
Country	:	US
Telephone Number	:	501-228-0063
Fax Number	:	501-228-0070

Provider Business Practice Location Address
First Line	:	1525 MERRILL DRIVE
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-1821
Country	:	US
Telephone Number	:	501-228-0063
Fax Number	:	501-228-0070

Authorized Official
Title or Position	:	CEO
Name	:	JOSH WILSON
Credential	:	PH.D.
Telephone Number	:	501-228-0063

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	05/07/2021

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