Basic Information
| Provider Information | |||||||||
| NPI: | 1407872773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDEPENDENT HEALTHCARE MANAGEMENT, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | S.E. LACKEY MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 6014694151 | ||||||||
| FaxNumber: | 6014693681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCNULTY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6018494112 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | CRT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 13033 | MS | Y | Hospital Units | Psychiatric Unit |
No ID Information.