=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609764554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL KELLYN THRALLS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2025
-----------------------------------------------------
Last Update Date | 06/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1402 E COUNTY LINE RD
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46227-0963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-887-7292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8170 CARMELITA CT
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46123-8879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-509-9267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 28201523A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------