MEDICARE: FIRST INTERMED CORPORATION

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		MS

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH0373	OTHER	MS	RAILROAD MEDICARE
2	CH9760	OTHER	MS	RAILROAD MEDICARE
3	CH7890	OTHER	MS	RAILROAD MEDICARE
4	CH7897	OTHER	MS	RAILROAD MEDICARE
6	CH7894	OTHER	MS	RAILROAD MEDICARE
7	CH7896	OTHER	MS	RAILROAD MEDICARE
8	CH0704	OTHER	MS	RAILROAD MEDICARE
9	CH7891	OTHER	MS	RAILROAD MEDICARE
10	CH7892	OTHER	MS	RAILROAD MEDICARE
11	CH7895	OTHER	MS	RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1669406658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST INTERMED CORPORATION

Provider Business Mailing Address
First Line	:	5606 OLD CANTON RD
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211-4217
Country	:	US
Telephone Number	:	601-957-3333
Fax Number	:	601-957-3334

Provider Business Practice Location Address
First Line	:	5606 OLD CANTON RD
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211-4217
Country	:	US
Telephone Number	:	601-957-3333
Fax Number	:	601-957-3334

Authorized Official
Title or Position	:	PHYSICIAN SERVICES COORDINATOR
Name	:	SAM SCOTT
Credential	:
Telephone Number	:	601-898-7525

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	03/30/2011

5604 OLD CANTON RD
JACKSON, MS
39211-4217

Practice Phone: 601-991-1044
Practice Fax: 601-991-9868