Provider Demographics
NPI:1194815449
Name:SMALL, GEORGE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROBERT
Last Name:SMALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-3634
Mailing Address - Country:US
Mailing Address - Phone:317-888-7745
Mailing Address - Fax:317-865-9007
Practice Address - Street 1:284 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-3634
Practice Address - Country:US
Practice Address - Phone:317-888-7745
Practice Address - Fax:317-865-9007
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022870A173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100151110AMedicaid
IN11068524/DF4194OtherMEDICARE RAILROAD
IN17300000XOtherTAXONOMY
IN87581OtherBLUE CROSS BLUE SHIELD
IN1245495142OtherGROUP NPI
IN232590AOtherMEDICARE GROUP PIN
IN232590AOtherMEDICARE GROUP PIN
IN100151110AMedicaid
IN430980Medicare PIN