NPIMap

Organization Active NPI

Independent Healthcare Management, Inc

Doing business as S.E. Lackey Memorial Hospital

  • Psychiatric Hospital Unit
  • Forest, MS
National Provider Identifier
1407872773
Registry record updated Dec 19, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Hospital UnitTaxonomy code 273R00000X
License
13033 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
Jul 13, 2006
Last updated
Dec 19, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 19, 2008

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

Authorized official

Name
Joseph S McNulty III, CRT
Title
President
Phone
(601) 849-4112

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X 13033 MS Primary

Addresses

Primary practice location

330 N Broad St
Forest, MS 39074-3508

Mailing address

PO Box 1100
Magee, MS 39111-1100
Phone (601) 849-6440

Other names 1

  • S.E. Lackey Memorial Hospital Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220809002665 MS Part A Provider - Critical Access Hospital 0840197232 Practice locations: Forest, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407872773. Details of each certification follow.

Hospital certification: CCN 25M300

Legal name
INDEPENDENT HEALTHCARE MANAGEMENT INC
Organization structure
CorporationNon-profit
Incorporated
in MS
Enrollment address
330N Broad St
S.E. Lackey Memorial Hospital
Forest, MS 39074-3508
Hospital Psychiatric Unit

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).

National Provider Directory

National Provider Directory

Member of 1

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

Ownership & related parties

All disclosed owners & managing parties 2

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 Contracted Managing EmployeeChairman of the Board Jan 2, 2018 100%
Corporate OfficerChairman of the Board Jan 1, 2018 100%
Corporate DirectorChairman of the Board Jan 1, 2018 100%
Operational/Managerial ControlChairman of the Board Jan 1, 2018 100%
Independent Healthcare Management Inc Organization, Forest, MS Corporation 5% Or Greater Direct Ownership Interest May 23, 2007 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
SE Lackey Memorial HospitalForest, MS, CCN 251300 Hospital 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Jan 1, 2019
Jan 1, 2019
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.

NPI Registry JSON

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

{
    "created_epoch": "1152748800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1229644800000",
    "number": "1407872773",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1100",
            "city": "MAGEE",
            "state": "MS",
            "postal_code": "391111100",
            "telephone_number": "601-849-6440",
            "fax_number": "601-849-7557"
        },
        {
            "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": [],
    "basic": {
        "organization_name": "INDEPENDENT HEALTHCARE MANAGEMENT, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-13",
        "last_updated": "2008-12-19",
        "status": "A",
        "authorized_official_last_name": "MCNULTY",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "601-849-4112",
        "authorized_official_name_suffix": "III",
        "authorized_official_credential": "CRT"
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "MS",
            "license": "13033",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "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.