=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811988355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY BLACKBURN C.N.M.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1633 N CAPITOL AVE SUITE 500
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-1261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-962-5014
-----------------------------------------------------
Fax | 317-962-2427
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3401 E RAYMOND ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46203-4744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-788-9769
-----------------------------------------------------
Fax | 317-781-4868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 72000011A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------