Healthcare Provider Details

I. General information

NPI: 1861427775
Provider Name (Legal Business Name): CCCG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SENATE BLVD METHODIST PROFESSIONAL CENTER, SUITE 310
INDIANAPOLIS IN
46202-1228
US

IV. Provider business mailing address

250 N SHADELAND AVE SUITE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-4836
  • Fax: 317-962-8646
Mailing address:
  • Phone: 317-962-4836
  • Fax: 317-962-8646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL L ODLE
Title or Position: PRESIDENT, CEO
Credential:
Phone: 317-962-4836