Basic Information
| Provider Information | |||||||||
| NPI: | 1134146582 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANAPOLIS NEUROSURGICAL GROUP | ||||||||
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| OtherOrganizationName: | GOODMAN CAMPBELL BRAIN AND SPINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8333 NAAB RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173961300 | ||||||||
| FaxNumber: | 3173961346 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 W 16TH ST | ||||||||
| Address2: | SUITE 5100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462022207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173961300 | ||||||||
| FaxNumber: | 3179248472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 04/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | CANTRELL | ||||||||
| AuthorizedOfficialFirstName: | DEREK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3173961386 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.