Provider Demographics
NPI:1689600587
Name:BLACKWELL, GERALD G (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:G
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:2050 MEADOWVIEW PARKWAY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7332
Practice Address - Country:US
Practice Address - Phone:423-230-5000
Practice Address - Fax:423-230-5097
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN27170207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5836361Medicaid
KY060034463Medicaid
TN621112685OtherUNITED HEALTH CARE
TN3094989Medicaid
VA5836361Medicaid
KY060034463Medicaid