Healthcare Provider Details

I. General information

NPI: 1407872773
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE MANAGEMENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N BROAD ST
FOREST MS
39074-3508
US

IV. Provider business mailing address

PO BOX 1100
MAGEE MS
39111-1100
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4151
  • Fax: 601-469-3681
Mailing address:
  • Phone: 601-849-6440
  • Fax: 601-849-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number13033
License Number StateMS

VIII. Authorized Official

Name: JOSEPH S MCNULTY III
Title or Position: PRESIDENT
Credential: CRT
Phone: 601-849-4112