Healthcare Provider Details

I. General information

NPI: 1427500958
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 HIGHWAY 35 S STE 3
FOREST MS
39074-8829
US

IV. Provider business mailing address

1123 HWY. 35 SOUTH
FOREST MS
39074
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10830
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN P LEE
Title or Position: CHAIRMAN OF THE BOARD
Credential:
Phone: 601-849-6440