Provider Demographics
NPI:1275130601
Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC
Entity Type:Organization
Organization Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-469-4861
Mailing Address - Street 1:100 PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-5501
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:
Practice Address - Street 1:9425 EASTSIDE DRIVE EXT STE B
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-8069
Practice Address - Country:US
Practice Address - Phone:601-683-0330
Practice Address - Fax:601-635-3746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS13033OtherLICENSE