Basic Information
| Provider Information | |||||||||
| NPI: | 1689600587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 MEADOWVIEW PARKWAY | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376607332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232305000 | ||||||||
| FaxNumber: | 4232305097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 27170 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 5836361 | 05 | VA | MEDICAID | 060034463 | 05 | KY | MEDICAID | 621112685 | 01 | TN | UNITED HEALTH CARE | OTHER | 3094989 | 05 | TN | MEDICAID |