Basic Information
| Provider Information | |||||||||
| NPI: | 1649761685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENT HEALTHCARE MANAGEMENT, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOREST FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PIONEER WAY | ||||||||
| Address2: | |||||||||
| City: | MAGEE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391115501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018496440 | ||||||||
| FaxNumber: | 6008491332 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL LN STE B | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390744039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014694861 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2018 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | COB | ||||||||
| AuthorizedOfficialTelephone: | 6014694861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.