MEDICARE: MARY BLACKBURN C.N.M.

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	367A00000X	Advanced Practice Midwife	72000011A	IN

General Provider Information

NPI Number	:	1811988355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BLACKBURN C.N.M.

Provider Business Mailing Address
First Line	:	3401 E RAYMOND ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-4744
Country	:	US
Telephone Number	:	317-788-9769
Fax Number	:	317-781-4868

Provider Business Practice Location Address
First Line	:	1633 N CAPITOL AVE
Second Line	:	SUITE 500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-1261
Country	:	US
Telephone Number	:	317-962-5014
Fax Number	:	317-962-2427

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	07/08/2007

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