Healthcare Provider Details

I. General information

NPI: 1346274354
Provider Name (Legal Business Name): FIRST INTERMED CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 HIGHWAY 49 S
RICHLAND MS
39218-9446
US

IV. Provider business mailing address

1132 HIGHWAY 49 S
RICHLAND MS
39218-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-664-1620
  • Fax: 601-664-1624
Mailing address:
  • Phone: 601-664-1620
  • Fax: 601-664-1624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: TONYA JORDAN
Title or Position: PHYSICIAN SERVICES COORDINATOR
Credential:
Phone: 601-898-7535