Provider Demographics
NPI:1396118378
Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity type:Organization
Organization Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COB
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:9427 EASTSIDE DRIVE EXT
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWTON
Mailing Address - State:MS
Mailing Address - Zip Code:39345-8063
Mailing Address - Country:US
Mailing Address - Phone:601-681-0330
Mailing Address - Fax:601-635-3746
Practice Address - Street 1:9427 EASTSIDE DRIVE EXT
Practice Address - Street 2:SUITE A
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-8063
Practice Address - Country:US
Practice Address - Phone:601-681-0330
Practice Address - Fax:601-635-3746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13-033261Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center