NPIMap

Individual provider Active NPI

Nerissa Licup, MD

  • Internal Medicine Physician
  • Kingsport, TN
National Provider Identifier
1720269731
Registry record updated Jun 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
46416 Issued in TN
Practice address
2205 Pavilion Dr Ste 101
Kingsport, TN 37660-4641
Phone
(423) 392-6000
Fax
(423) 392-6030
NPI assigned
Nov 19, 2007
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 10, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Internal Medicine Physician 207R00000X 46416 TN Primary

Addresses

Primary practice location

2205 Pavilion Dr Ste 101
Kingsport, TN 37660-4641

Mailing address

1021 W Oakland Ave Ste 310
Johnson City, TN 37604-2192
Phone (423) 302-6565

Other practice location 1

1 Medical Park Blvd Ste 200E
Bristol, TN 37620-7498
Phone (423) 844-5100

Other practice location 2

111 W Stone Dr Ste 200
Kingsport, TN 37660-6028
Phone (423) 723-2030

Other practice location 3

115 Judge Gresham Rd Ste A
Gray, TN 37615-6213
Phone (423) 467-3000

Other identifiers 4

IdentifierTypeStateIssuer
4276956OtherTNBLUECARE
1521020MedicaidTN
P01015971OtherTNRR MEDICARE
1720269731MedicaidVA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20101117000937 TN Practitioner - Internal Medicine 5496940363 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Other, 2004
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

2205 Pavilion Dr
Suite 101
Kingsport, TN 37660-4641
Phone (423) 392-6000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
46416TNMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Blue Ridge Medical Management Corporation Internal Medicine CurrentSince Aug 13, 2010 Accepting new patients
Blue Ridge Medical Management Corporation Current Accepting new patients
Blue Ridge Medical Management Corporation Past Accepting new patients

Locations

1021 W Oakland Ave
Ste 310
Johnson City, TN 37604
Phone (423) 302-6565

2205 Pavilion Dr
Ste 101
Kingsport, TN 37660
Phone (423) 392-6000

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1195430400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1717977600000",
    "number": "1720269731",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1021 W OAKLAND AVE STE 310",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376042192",
            "telephone_number": "423-302-6565"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2205 PAVILION DR STE 101",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376604641",
            "telephone_number": "423-392-6000",
            "fax_number": "423-392-6030"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1 Medical Park Blvd Ste 200E",
            "address_purpose": "LOCATION",
            "city": "Bristol",
            "state": "TN",
            "postal_code": "376207498",
            "country_code": "US",
            "telephone_number": "423-844-5100",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "111 W Stone Dr Ste 200",
            "address_purpose": "LOCATION",
            "city": "Kingsport",
            "state": "TN",
            "postal_code": "376606028",
            "country_code": "US",
            "telephone_number": "423-723-2030",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "115 Judge Gresham Rd Ste A",
            "address_purpose": "LOCATION",
            "city": "Gray",
            "state": "TN",
            "postal_code": "376156213",
            "country_code": "US",
            "telephone_number": "423-467-3000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LICUP",
        "first_name": "NERISSA",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-11-19",
        "last_updated": "2024-06-10",
        "certification_date": "2024-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "TN",
            "license": "46416",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUECARE",
            "identifier": "4276956",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1521020",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P01015971",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1720269731",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kingsport, TN

Sources for this page

Verify at the official NPI Registry.