Provider Demographics
NPI:1841358017
Name:GREEN-MACK, THELMA LYNETTE (MD)
Entity type:Individual
Prefix:
First Name:THELMA
Middle Name:LYNETTE
Last Name:GREEN-MACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 SHORE DRIVE
Mailing Address - Street 2:SUIOTE 305
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5621
Mailing Address - Country:US
Mailing Address - Phone:317-920-3220
Mailing Address - Fax:317-920-3221
Practice Address - Street 1:3850 SHORE DRIVE
Practice Address - Street 2:SUIOTE 305
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5621
Practice Address - Country:US
Practice Address - Phone:317-920-3220
Practice Address - Fax:317-920-3221
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037601B208100000X
IN010376012081P2900X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100130200Medicaid
IN250010985OtherRAILROAD MEDICARE
IN000000092241OtherANTHEM BCBS
IN1841358017OtherNPI
IN674680Medicare ID - Type Unspecified
IN000000092241OtherANTHEM BCBS
INB62415Medicare UPIN