Provider Demographics
NPI:1720277544
Name:GRAND OLD DOCS OF THE SOUTHSIDE
Entity Type:Organization
Organization Name:GRAND OLD DOCS OF THE SOUTHSIDE
Other - Org Name:CENTRAL INDIANA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:DICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-882-0535
Mailing Address - Street 1:1350 E COUNTY LINE RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-0873
Mailing Address - Country:US
Mailing Address - Phone:317-882-0535
Mailing Address - Fax:317-882-0173
Practice Address - Street 1:8920 SOUTHPOINTE DR
Practice Address - Street 2:SUITE E-1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7509
Practice Address - Country:US
Practice Address - Phone:317-882-0535
Practice Address - Fax:317-882-0173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022713A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCI4722OtherGROUP RR MCE #
INCI4722OtherGROUP RR MCE #
INC24263Medicare UPIN