MEDICARE: GRAND OLD DOCS OF THE SOUTHSIDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CI4722	OTHER	IN	GROUP RR MEDICARE NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5457630003	OTHER	IN	DME

General Provider Information

NPI Number	:	1790886844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND OLD DOCS OF THE SOUTHSIDE

Provider Business Mailing Address
First Line	:	1350 E COUNTY LINE RD
Second Line	:	SUITE I
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-0873
Country	:	US
Telephone Number	:	317-865-9090
Fax Number	:	317-865-0523

Provider Business Practice Location Address
First Line	:	360 S MADISON AVE
Second Line	:	#200
City	:	GREENWOOD
State	:	IN
Zip	:	46142-3150
Country	:	US
Telephone Number	:	317-865-9090
Fax Number	:	317-865-0523

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	BRENDA R RUSSELL
Credential	:	MD
Telephone Number	:	317-865-9090

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	06/30/2008

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Directions to “GRAND OLD DOCS OF THE SOUTHSIDE ” Practice Location

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