Basic Information
| Provider Information | |||||||||
| NPI: | 1952326241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENT HEALTHCARE MANAGEMENT, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | S.E. LACKEY MEMORIAL HOSPITAL | ||||||||
| 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: | 6014694151 | ||||||||
| FaxNumber: | 6014693681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| 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 | 275N00000X | 13-033 | MS | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 00220378 | 05 | MS | MEDICAID |