MEDICARE: BLUE RIDGE MEDICAL MANAGEMENT C ORPORATION

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
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1861013864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE MEDICAL MANAGEMENT C ORPORATION

Provider Business Mailing Address
First Line	:	509 MED TECH PKWY STE 100
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2579
Country	:	US
Telephone Number	:	423-952-2111
Fax Number	:	423-952-2175

Provider Business Practice Location Address
First Line	:	403 PRINCETON RD STE 10
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2062
Country	:	US
Telephone Number	:	423-431-7340
Fax Number	:	423-431-7345

Authorized Official
Title or Position	:	EXC VP
Name	:	MARVIN EICHORN
Credential	:
Telephone Number	:	423-302-3272

Provider Enumeration Date	:	04/30/2020
Last Update Date	:	05/01/2025

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