Provider Demographics
NPI:1477653509
Name:GRAND OLE DOCS OF THE SOUTHSIDE, LLC
Entity Type:Organization
Organization Name:GRAND OLE DOCS OF THE SOUTHSIDE, LLC
Other - Org Name:CENTRAL INDIANA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICHERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-881-5152
Mailing Address - Street 1:1350 E COUNTY LINE RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-0873
Mailing Address - Country:US
Mailing Address - Phone:317-887-7725
Mailing Address - Fax:317-887-7751
Practice Address - Street 1:365 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1361
Practice Address - Country:US
Practice Address - Phone:317-881-5152
Practice Address - Fax:317-881-8993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5457630006OtherDME
INCI4722OtherGROUP RR MEDICARE NUMBER
IN132440Medicare PIN