Provider Demographics
NPI:1952694994
Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type:Organization
Organization Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Other - Org Name:MAIN STREET MEDICAL CLINIC OF MORTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
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 1:347 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-3407
Mailing Address - Country:US
Mailing Address - Phone:601-732-1524
Mailing Address - Fax:601-732-1572
Practice Address - Street 1:347 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MS
Practice Address - Zip Code:39117-3407
Practice Address - Country:US
Practice Address - Phone:601-732-1524
Practice Address - Fax:601-732-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS258570Medicare Oscar/Certification