Healthcare Provider Details

I. General information

NPI: 1649761685
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE MANAGEMENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL LN STE B
FOREST MS
39074-4039
US

IV. Provider business mailing address

100 PIONEER WAY
MAGEE MS
39111-5501
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4861
  • Fax:
Mailing address:
  • Phone: 601-849-6440
  • Fax: 600-849-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHN P LEE
Title or Position: COB
Credential: MD
Phone: 601-469-4861