Provider Demographics
NPI:1760778609
Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type:Organization
Organization Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Other - Org Name:MAIN STREET MEDICAL CLINIC OF SEBASTOPOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:17509 HWY 21
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:MS
Mailing Address - Zip Code:39359-0000
Mailing Address - Country:US
Mailing Address - Phone:601-625-9818
Mailing Address - Fax:601-625-9904
Practice Address - Street 1:17509 HWY 21
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:MS
Practice Address - Zip Code:39359-0000
Practice Address - Country:US
Practice Address - Phone:601-625-9818
Practice Address - Fax:601-625-9904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS258569Medicare Oscar/Certification