Provider Demographics
NPI:1740634500
Name:MIMA INC.
Entity type:Organization
Organization Name:MIMA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-616-8052
Mailing Address - Street 1:1728 MARION WALDO RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-7457
Mailing Address - Country:US
Mailing Address - Phone:740-389-2297
Mailing Address - Fax:740-888-0004
Practice Address - Street 1:1069 DELAWARE AVE
Practice Address - Street 2:STE 105
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-1400
Practice Address - Country:US
Practice Address - Phone:740-382-9024
Practice Address - Fax:740-888-1871
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST INTERNAL MEDICINE ASSOC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3890924174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty