1316557986 NPI number — INDEPENDENT HEALTHCARE MANAGEMENT INC

Table of content: (NPI 1316557986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316557986 NPI number — INDEPENDENT HEALTHCARE MANAGEMENT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENT HEALTHCARE MANAGEMENT INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
149 PEDIATRIC AND FAMILY CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316557986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39074-0558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-469-4151
Provider Business Mailing Address Fax Number:
601-469-9927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
376 SIMPSON HIGHWAY 149 STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAGEE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39111-3569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-849-6440
Provider Business Practice Location Address Fax Number:
601-849-1332
Provider Enumeration Date:
08/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
601-469-4151

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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