Healthcare Provider Details

I. General information

NPI: 1609898865
Provider Name (Legal Business Name): GREGORY D BLACKMON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7714 CONNER RD SUITE 101
POWELL TN
37849-3559
US

IV. Provider business mailing address

7714 CONNER RD SUITE 101
POWELL TN
37849-3559
US

V. Phone/Fax

Practice location:
  • Phone: 865-212-6350
  • Fax: 865-212-6350
Mailing address:
  • Phone: 865-212-6350
  • Fax: 865-212-6350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28729
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: