Provider Demographics
NPI:1669406658
Name:FIRST INTERMED CORPORATION
Entity type:Organization
Organization Name:FIRST INTERMED CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN SERVICES COORDINATOR
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 1:5606 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4217
Mailing Address - Country:US
Mailing Address - Phone:601-957-3333
Mailing Address - Fax:601-957-3334
Practice Address - Street 1:5606 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4217
Practice Address - Country:US
Practice Address - Phone:601-957-3333
Practice Address - Fax:601-957-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-03-30
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
MSCH0373OtherRAILROAD MEDICARE
MSCH9760OtherRAILROAD MEDICARE
MSCH7890OtherRAILROAD MEDICARE
MSCH7897OtherRAILROAD MEDICARE
MS09015301Medicaid
MSCH7894OtherRAILROAD MEDICARE
MSCH7896OtherRAILROAD MEDICARE
MSCH0704OtherRAILROAD MEDICARE
MSCH7891OtherRAILROAD MEDICARE
MSCH7892OtherRAILROAD MEDICARE
MSCH7895OtherRAILROAD MEDICARE
MSCH7890OtherRAILROAD MEDICARE