Basic Information
| Provider Information | |||||||||
| NPI: | 1710268412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMINIAN WILMOT | ||||||||
| FirstName: | AMIN | ||||||||
| MiddleName: | HANOI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | RCS PROVIDER ENROLLMENT | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657411515 | ||||||||
| FaxNumber: | 7657515087 | ||||||||
| Practice Location | |||||||||
| Address1: | 2776 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339015855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2011 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01078506 | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME113450 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 73475 | WI | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 01078506A | IN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 100099963 | 05 | WI | MEDICAID |