Healthcare Provider Details

I. General information

NPI: 1245905405
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 AIRPORT RD
FOREST MS
39074-4032
US

IV. Provider business mailing address

PO BOX 1460
MAGEE MS
39111-1460
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4151
  • Fax: 601-469-3681
Mailing address:
  • Phone: 601-849-6440
  • Fax: 601-849-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN LEE
Title or Position: CHAIRMAN OF BOARD
Credential: MD
Phone: 601-469-4861