Provider Demographics
NPI:1942260112
Name:BLACKWELDER, REID B (MD)
Entity Type:Individual
Prefix:
First Name:REID
Middle Name:B
Last Name:BLACKWELDER
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-245-9600
Mailing Address - Fax:423-245-9634
Practice Address - Street 1:102 E RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-245-9600
Practice Address - Fax:423-245-9634
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ011980Medicaid
TN3070818Medicare PIN