Organization
GRAND OLE DOCS OF THE SOUTHSIDE, LLC
Active
Other names
Central Indiana Medical Group
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY N DEWESTER MD (OWNER)
(317) 807-0247
Entity
Organization
Contact information
Practice address
6349 S EAST ST, INDIANAPOLIS, IN 46227-7107
(317) 807-0247
(317) 735-1951
Mailing address
1350 E COUNTY LINE RD, SUITE H, INDIANAPOLIS, IN 46227-0873
(317) 887-7725
(317) 887-7751
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01036126A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5457630005
DME
IN
01
—
CI4722
GROUP RR MEDICARE #
IN
Enumeration date
11/14/2007
Last updated
12/05/2013
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