Basic Information
Provider Information | |||||||||
NPI: | 1255376729 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INDEPENDENT HEALTHCARE MANAGEMENT, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1100 | ||||||||
Address2: |   | ||||||||
City: | MAGEE | ||||||||
State: | MS | ||||||||
PostalCode: | 391111100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018496440 | ||||||||
FaxNumber: | 6018497557 | ||||||||
Practice Location | |||||||||
Address1: | 330 N BROAD ST | ||||||||
Address2: |   | ||||||||
City: | FOREST | ||||||||
State: | MS | ||||||||
PostalCode: | 390743508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014694771 | ||||||||
FaxNumber: | 6014694724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2006 | ||||||||
LastUpdateDate: | 05/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEE | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN OF THE BOARD | ||||||||
AuthorizedOfficialTelephone: | 6018496440 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 00126171 | 05 | MS |   | MEDICAID |