MEDICARE: MARINA NICHOLE BLACKWELL DPM

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1538953534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA NICHOLE BLACKWELL DPM

Provider Business Mailing Address
First Line	:	3265 S SOUTHERN OAKS DR
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-8000
Country	:	US
Telephone Number	:	812-340-2738
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 E GALBRAITH RD STE 205
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45236-3557
Country	:	US
Telephone Number	:	513-853-8884
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2025
Last Update Date	:	04/07/2025

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