MEDICARE: CENTER FOR SPINE & SPORTS REHABILITATION PC

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	208100000X	Physical Medicine & Rehabilitation Physician	01037601B	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	250010985	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10815817	OTHER	IN	CAQH - COUNCIL FOR AFFORDABLE QUALITY HEALTHCARE
2	1346439239	OTHER	IN	NPI NATIONAL PROVIDER IDENTIFER GROUP
4	1841358017	OTHER	IN	NPI NATIONAL PROVIDER IDENTIFER INDIVIDUAL
5	000000092241	OTHER	IN	ANTHEM BCBS

General Provider Information

NPI Number	:	1346439239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR SPINE & SPORTS REHABILITATION PC

Provider Business Mailing Address
First Line	:	3850 SHORE DR STE 305
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-4693
Country	:	US
Telephone Number	:	317-920-3220
Fax Number	:	317-920-3221

Provider Business Practice Location Address
First Line	:	3850 SHORE DR STE 305
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-4693
Country	:	US
Telephone Number	:	317-920-3220
Fax Number	:	317-920-3222

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. THELMA LYNETTE GREEN-MACK
Credential	:	MD
Telephone Number	:	317-920-3220

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	02/22/2023

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Directions to “CENTER FOR SPINE & SPORTS REHABILITATION PC ” Practice Location

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