=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841358017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THELMA LYNETTE GREEN-MACK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 03/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3850 SHORE DRIVE SUIOTE 305
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-5621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-920-3220
-----------------------------------------------------
Fax | 317-920-3221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3850 SHORE DRIVE SUIOTE 305
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-5621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-920-3220
-----------------------------------------------------
Fax | 317-920-3221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 01037601B
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 01037601
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 01037601
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------