Provider Demographics
NPI:1689903635
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:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:317-396-1300
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 1:1001 W 10TH ST
Practice Address - Street 2:RG 4TH FLOOR
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2859
Practice Address - Country:US
Practice Address - Phone:317-630-7625
Practice Address - Fax:317-630-8721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100318390Medicaid
IN100318390Medicaid