Healthcare Provider Details

I. General information

NPI: 1295465805
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 AIRPORT RD
FOREST MS
39074-4032
US

IV. Provider business mailing address

360 SIMPSON HIGHWAY 149 STE 140
MAGEE MS
39111-3840
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4151
  • Fax:
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: COB
Credential: MD
Phone: 601-469-4861