Grand Old Docs of the Southside

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

GRAND OLD DOCS OF THE SOUTHSIDE

Doing business as

Central Indiana Medical Group

Practice address

360 S Madison Ave
#200
Greenwood, IN 46142-3150

Phone

(317) 865-9090

Fax

(317) 865-0523

NPI assigned

Sep 25, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Brenda R Russell, MD

Title

Physician

Phone

(317) 865-9090

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Central Indiana Medical Group Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159142400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1214784000000",
    "number": "1790886844",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1350 E COUNTY LINE RD",
            "address_2": "SUITE I",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462270873",
            "telephone_number": "317-865-9090",
            "fax_number": "317-865-0523"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "360 S MADISON AVE",
            "address_2": "#200",
            "city": "GREENWOOD",
            "state": "IN",
            "postal_code": "461423150",
            "telephone_number": "317-865-9090",
            "fax_number": "317-865-0523"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND OLD DOCS OF THE SOUTHSIDE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-25",
        "last_updated": "2008-06-30",
        "status": "A",
        "authorized_official_last_name": "RUSSELL",
        "authorized_official_first_name": "BRENDA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "317-865-9090",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DME",
            "identifier": "5457630003",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP RR MEDICARE NUMBER",
            "identifier": "CI4722",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Central Indiana Medical Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Carrie Michelle Gould, M.D.
• Michael Robert Gould, O.D.
• Jason Goy
• Braeshel Darletha Graham
• Grand Brook Memory Care of Greenwood LLC
• Grand Old Docs of the Southside
• Grand Ole Docs of the Southside, LLC
• Grand Ole Docs of the Southside, LLC
• Kelly Carlberg Graner, M.D.
• Alyson M Grantham

• Family Medicine Physician in Greenwood, IN
• Providers in Greenwood, IN by specialty
• Family Medicine Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 30, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.