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NPI Code Detail

MEDICARE: BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

MEDICARE: BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0804XChild & Adolescent Psychiatry Physician
22084P0800XPsychiatry Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
3CA5744OTHERRR MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2801453000OTHERTNMAGELLAN
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1326058272
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Provider Business Mailing Address
First Line : 403 N STATE OF FRANKLIN RD
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37604-6034
Country : US
Telephone Number : 423-431-7047
Fax Number : 423-979-0569
Provider Business Practice Location Address
First Line : 403 N STATE OF FRANKLIN RD
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37604-6034
Country : US
Telephone Number : 423-431-7047
Fax Number : 423-979-0569
Authorized Official
Title or Position : PRESIDENT
Name : CARL STEVEN KILGORE
Credential :
Telephone Number : 423-302-3051
Provider Enumeration Date : 08/09/2006
Last Update Date : 03/29/2019

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Directions to “BLUE RIDGE MEDICAL MANAGEMENT CORPORATION ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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