Provider Demographics
NPI:1750327565
Name:BLACKBURN, SHELLEY L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:L
Last Name:BLACKBURN
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 1:4626 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2247
Mailing Address - Country:US
Mailing Address - Phone:614-538-9339
Mailing Address - Fax:614-538-9162
Practice Address - Street 1:4626 SAWMILL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2247
Practice Address - Country:US
Practice Address - Phone:614-538-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057267B207Q00000X
OH35057267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0768745Medicaid
080193046OtherMEDICARE RAILROAD
000000251080OtherANTHEM
080193046OtherMEDICARE RAILROAD
E36614Medicare UPIN