Provider Demographics
NPI:1851487706
Name:GRAND OLE DOCS OF THE SOUTHSIDE
Entity Type:Organization
Organization Name:GRAND OLE DOCS OF THE SOUTHSIDE
Other - Org Name:CENTRAL INDIANA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEWESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-882-0535
Mailing Address - Street 1:8921 SOUTHPOINTE DR
Mailing Address - Street 2:B1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-0968
Mailing Address - Country:US
Mailing Address - Phone:317-882-0535
Mailing Address - Fax:317-882-1415
Practice Address - Street 1:8921 SOUTHPOINTE DR
Practice Address - Street 2:B1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0968
Practice Address - Country:US
Practice Address - Phone:317-882-0535
Practice Address - Fax:317-882-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01018751A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN132440Medicare PIN