Provider Demographics
NPI:1639103625
Name:FIRST INTERMED CORPORATION
Entity Type:Organization
Organization Name:FIRST INTERMED CORPORATION
Other - Org Name:MEA MEDICAL CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-898-7525
Mailing Address - Street 1:342 GILCHRIST DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-6671
Mailing Address - Country:US
Mailing Address - Phone:601-939-0700
Mailing Address - Fax:601-939-8654
Practice Address - Street 1:342 GILCHRIST DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-6671
Practice Address - Country:US
Practice Address - Phone:601-939-0700
Practice Address - Fax:601-939-8654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015301Medicaid
MSCH7896OtherRAILROAD MEDICARE
MSCH7896OtherRAILROAD MEDICARE