# GRAND OLD DOCS OF THE SOUTHSIDE

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Central Indiana Medical Group
- **Organization subpart:** No

## Provider details

- **NPI number:** 1790886844
- **Authorized official:** BRENDA R RUSSELL MD (PHYSICIAN)
- **Authorized official phone:** (317) 865-9090

## Contact information

- **Practice address:** 360 S MADISON AVE, \#200, GREENWOOD, IN 46142-3150
- **Practice address phone:** (317) 865-9090
- **Practice address fax:** (317) 865-0523
- **Mailing address:** 1350 E COUNTY LINE RD, SUITE I, INDIANAPOLIS, IN 46227-0873
- **Mailing address phone:** (317) 865-9090
- **Mailing address fax:** (317) 865-0523

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 09/25/2006
- **Last updated:** 06/30/2008