=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386331643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOUL FAMILY MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2023
-----------------------------------------------------
Last Update Date | 08/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5128 E STOP 11 RD STE 38
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46237-6338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-410-0371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5128 E STOP 11 RD STE 38
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46237-6338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-410-0371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RHONDA WILSON GOUL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 317-410-0371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------