NPIMap

Organization Active NPI

Independent Healthcare Management, Inc.

Doing business as S E Lackey Memorial Hospital

  • Critical Access Hospital
  • Forest, MS
National Provider Identifier
1306909734
Registry record updated Jul 26, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
License
13-033 Issued in MS
Legal business name
INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Doing business as
S E Lackey Memorial Hospital
Practice address
330 N Broad St
Forest, MS 39074-3508
Phone
(601) 469-4151
Fax
(601) 469-3681
NPI assigned
Dec 18, 2006
Last updated
Jul 26, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 26, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. John P LeeNPI 1992806699
Title
Chairman of the Board
Phone
(601) 469-4771

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X 13-033 MS Primary

Addresses

Primary practice location

330 N Broad St
Forest, MS 39074-3508

Mailing address

PO Box D
Forest, MS 39074-0558
Phone (601) 469-4151

Other practice location 1

505 Airport Rd Ste F
Forest, MS 39074-4033
Phone (601) 333-0947

Other identifiers 3

IdentifierTypeStateIssuer
09013565MedicaidMS
00220324MedicaidMS
09013844MedicaidMS

Other names 1

  • S E Lackey Memorial Hospital Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031215000487 MS Part B Supplier - Clinic/Group Practice 0840197232 Receives reassigned benefits from 95 practitioners
13 other NPIs on this enrollment
Practice locations: Raleigh, MS; Newton, MS; Morton, MS; Magee, MS; Forest, MS
O20120111000488 MS Part A Provider - Critical Access Hospital 0840197232 Receives reassigned benefits from 70 practitioners
Practice locations: Forest, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1306909734. Details of each certification follow.

Hospital certification: CCN 251300

Legal name
INDEPENDENT HEALTHCARE MANAGEMENT INC
Doing business as
SE LACKEY MEMORIAL HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Sep 11, 2000
Last certification
Jul 25, 2007
Beds
35
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Jan 10, 1989 in MS
Enrollment address
330 N Broad St
Forest, MS 39074-3508
Other Hospital Practice Location

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

Care Compare: Hospital

Medicare Care Compare
Listed as
S E Lackey Memorial HospitalCCN 251300 · All quality measures
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

105 N Van Buren St
Carthage, MS 39051
Phone (601) 298-9500

504 Airport Rd
Ste C
Forest, MS 39074
Phone (601) 469-2732

505 Airport Rd
Ste B
Forest, MS 39074
Phone (601) 469-4771

505 Airport Rd
Ste D
Forest, MS 39074
Phone (601) 333-0947

505 Airport Rd
Ste G
Forest, MS 39074
Phone (601) 333-0947

360 Simpson Highway 149
Ste 140
Magee, MS 39111

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
John P Lee Individual Corporate OfficerChairman of the Board Oct 14, 2016 100%
Corporate DirectorChairman of the Board Oct 14, 2016 100%
Operational/Managerial ControlChairman of the Board Oct 14, 2016 100%
Independent Healthcare Management Inc Organization, Forest, MS Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2019
Operational/Managerial Control Jan 1, 2019
Sydney Sawyer Individual Corporate DirectorAdministrator Jan 1, 2016 100%
Operational/Managerial ControlAdministrator Jan 1, 2016 100%

Owners & managing parties with NPI records 9

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 8

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Independent Healthcare Management IncForest, MS, CCN 25M300 Hospital 5% Or Greater Direct Ownership Interest (100%) May 23, 2007
SE Lackey Memorial HospitalForest, MS, CCN 25Z300 Hospital 5% Or Greater Direct Ownership Interest (100%) May 23, 2007
Community Health ClinicForest, MS, CCN 258504 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Aug 14, 1989
Main Street Medical Clinic of MortonMorton, MS, CCN 258570 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Sep 9, 2015
Sep 9, 2015
Lackey Pediatric ClinicForest, MS, CCN 258608 Rural health clinic Operational/Managerial Control (100%) Jan 1, 2018
Newton Family and Pediatric ClinicNewton, MS, CCN 258617 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Aug 14, 1989
Aug 14, 1989
Independent Healthcare Management IncMagee, MS, CCN 258653 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Sep 1, 2020
Sep 1, 2020
Independent Healthcare Management IncRaleigh, MS, CCN 258684 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jul 17, 2023
Jul 1, 2023

Owned or controlled facilities with NPI records 8

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 8

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 111

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 111

Affiliated clinicians 78

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 78

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166400000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690329600000",
    "number": "1306909734",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX D",
            "city": "FOREST",
            "state": "MS",
            "postal_code": "390740558",
            "telephone_number": "601-469-4151"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "330 N BROAD ST",
            "city": "FOREST",
            "state": "MS",
            "postal_code": "390743508",
            "telephone_number": "601-469-4151",
            "fax_number": "601-469-3681"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "505 Airport Rd Ste F",
            "address_purpose": "LOCATION",
            "city": "Forest",
            "state": "MS",
            "postal_code": "390744033",
            "country_code": "US",
            "telephone_number": "601-333-0947",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "INDEPENDENT HEALTHCARE MANAGEMENT, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-18",
        "last_updated": "2023-07-26",
        "certification_date": "2023-07-26",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "CHAIRMAN OF THE BOARD",
        "authorized_official_telephone_number": "601-469-4771",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "MS",
            "license": "13-033",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09013565",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00220324",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09013844",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "S E Lackey Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "S E Lackey Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Forest, MS

Sources for this page

Verify at the official NPI Registry.