Provider Demographics
NPI:1639359037
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:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:DEWESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-807-0247
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 1:6349 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7107
Practice Address - Country:US
Practice Address - Phone:317-807-0247
Practice Address - Fax:317-735-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036126A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCI4722OtherGROUP RR MEDICARE #
IN5457630005OtherDME
INCI4722OtherGROUP RR MEDICARE #