Organization
GRAND OLD DOCS OF THE SOUTHSIDE
Active
Other names
Central Indiana Medical Group
Organization subpart
No
Provider details
NPI number
Authorized official
BRENDA R RUSSELL MD (PHYSICIAN)
(317) 865-9090
Entity
Organization
Contact information
Practice address
360 S MADISON AVE, #200, GREENWOOD, IN 46142-3150
(317) 865-9090
(317) 865-0523
Mailing address
1350 E COUNTY LINE RD, SUITE I, INDIANAPOLIS, IN 46227-0873
(317) 865-9090
(317) 865-0523
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5457630003
DME
IN
01
—
CI4722
GROUP RR MEDICARE NUMBER
IN
Enumeration date
09/25/2006
Last updated
06/30/2008
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