Provider Demographics
NPI:1518978766
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:317-396-1300
Mailing Address - Street 1:10603 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1055
Mailing Address - Country:US
Mailing Address - Phone:317-396-1300
Mailing Address - Fax:
Practice Address - Street 1:10603 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1055
Practice Address - Country:US
Practice Address - Phone:317-396-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100318390KMedicaid