=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437167194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKMON PEDIATRICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7714 CONNER RD SUITE 101
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37849-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-212-6350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7714 CONNER RD SUITE 101
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37849-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-212-6350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | AUBREY WELLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-212-6441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------