1871693994 NPI number — GRAND OLE DOCS OF THE SOUTHSIDE, LLC

Table of content: (NPI 1871693994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871693994 NPI number — GRAND OLE DOCS OF THE SOUTHSIDE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND OLE DOCS OF THE SOUTHSIDE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTRAL INDIANA MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871693994
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 E COUNTY LINE RD
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46227-0873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-887-7725
Provider Business Mailing Address Fax Number:
317-887-7751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143-1361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-881-5152
Provider Business Practice Location Address Fax Number:
317-881-8993
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLAASEN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
V
Authorized Official Title or Position:
MANAGING PHYSICIAN
Authorized Official Telephone Number:
317-882-6663

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CI4722 . This is a "GROUP RR MEDICARE #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 5457630001 . This is a "DME" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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