Provider Demographics
NPI:1669816799
Name:ADVANCED SURGERY OF INDIANA LLC
Entity Type:Organization
Organization Name:ADVANCED SURGERY OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-679-1757
Mailing Address - Street 1:PO BOX 56051
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-0051
Mailing Address - Country:US
Mailing Address - Phone:317-598-0094
Mailing Address - Fax:
Practice Address - Street 1:9470 BRIDGEWATER CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3412
Practice Address - Country:US
Practice Address - Phone:317-598-0094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068514A261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200986830Medicaid
INM400051720Medicare PIN