1790886844 NPI number — GRAND OLD DOCS OF THE SOUTHSIDE

Table of content: (NPI 1790886844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790886844 NPI number — GRAND OLD DOCS OF THE SOUTHSIDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND OLD DOCS OF THE SOUTHSIDE
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:
Provider Other Organization Name Type Code:
6
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:
1790886844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
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 I
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:
317-865-9090
Provider Business Mailing Address Fax Number:
317-865-0523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 S MADISON AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46142-3150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-865-9090
Provider Business Practice Location Address Fax Number:
317-865-0523
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
317-865-9090

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: 5457630003 . This is a "DME" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: CI4722 . This is a "GROUP RR MEDICARE NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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