Provider Demographics
NPI:1134146582
Name:INDIANAPOLIS NEUROSURGICAL GROUP
Entity Type:Organization
Organization Name:INDIANAPOLIS NEUROSURGICAL GROUP
Other - Org Name:GOODMAN CAMPBELL BRAIN AND SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-396-1386
Mailing Address - Street 1:8333 NAAB RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5924
Mailing Address - Country:US
Mailing Address - Phone:317-396-1300
Mailing Address - Fax:317-396-1346
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:SUITE 5100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-396-1300
Practice Address - Fax:317-924-8472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4723080003Medicare NSC
061570Medicare ID - Type Unspecified