Provider Demographics
NPI:1578987152
Name:MIMMS FUNCTIONAL REHABILITATION PC
Entity Type:Organization
Organization Name:MIMMS FUNCTIONAL REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-450-2113
Mailing Address - Street 1:6325 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7110
Mailing Address - Country:US
Mailing Address - Phone:317-781-0067
Mailing Address - Fax:317-791-1242
Practice Address - Street 1:6325 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:317-781-0067
Practice Address - Fax:317-791-1242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059908208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2012803330AMedicaid
IN200500320Medicaid
IN899980TMedicare PIN