Healthcare Provider Details

I. General information

NPI: 1275567281
Provider Name (Legal Business Name): FIRST INTERMED CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 S SIWELL RD
BYRAM MS
39272-9772
US

IV. Provider business mailing address

7300 S SIWELL RD
BYRAM MS
39272-9772
US

V. Phone/Fax

Practice location:
  • Phone: 601-373-1234
  • Fax: 601-373-1397
Mailing address:
  • Phone: 601-373-1234
  • Fax: 601-373-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: SAM SCOTT
Title or Position: CFO
Credential:
Phone: 601-898-7525