Basic Information
| Provider Information | |||||||||
| NPI: | 1669406658 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRST INTERMED CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MEA MEDICAL CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5606 OLD CANTON RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392114217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019573333 | ||||||||
| FaxNumber: | 6019573334 | ||||||||
| Practice Location | |||||||||
| Address1: | 5606 OLD CANTON RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392114217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019573333 | ||||||||
| FaxNumber: | 6019573334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN SERVICES COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6018987525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH0373 | 01 | MS | RAILROAD MEDICARE | OTHER | CH9760 | 01 | MS | RAILROAD MEDICARE | OTHER | CH7890 | 01 | MS | RAILROAD MEDICARE | OTHER | CH7897 | 01 | MS | RAILROAD MEDICARE | OTHER | 09015301 | 05 | MS | MEDICAID | CH7894 | 01 | MS | RAILROAD MEDICARE | OTHER | CH7896 | 01 | MS | RAILROAD MEDICARE | OTHER | CH0704 | 01 | MS | RAILROAD MEDICARE | OTHER | CH7891 | 01 | MS | RAILROAD MEDICARE | OTHER | CH7892 | 01 | MS | RAILROAD MEDICARE | OTHER | CH7895 | 01 | MS | RAILROAD MEDICARE | OTHER |