Provider Demographics
NPI:1346439239
Name:CENTER FOR SPINE & SPORTS REHABILITATION PC
Entity Type:Organization
Organization Name:CENTER FOR SPINE & SPORTS REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:GREEN-MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-920-3220
Mailing Address - Street 1:3850 SHORE DR STE 305
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4693
Mailing Address - Country:US
Mailing Address - Phone:317-920-3220
Mailing Address - Fax:317-920-3221
Practice Address - Street 1:3850 SHORE DR STE 305
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4693
Practice Address - Country:US
Practice Address - Phone:317-920-3220
Practice Address - Fax:317-920-3222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037601B208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10815817OtherCAQH - COUNCIL FOR AFFORDABLE QUALITY HEALTHCARE
IN1346439239OtherNPI NATIONAL PROVIDER IDENTIFER GROUP
IN250010985OtherRAILROAD MEDICARE
IN1841358017OtherNPI NATIONAL PROVIDER IDENTIFER INDIVIDUAL
IN000000092241OtherANTHEM BCBS
IN000000092241OtherANTHEM BCBS
IN674680Medicare Oscar/Certification
IN000000092241OtherANTHEM BCBS