Healthcare Provider Details

I. General information

NPI: 1255634564
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 WEST ELK AVE SUITE 21
ELIZABETHTON TN
37643
US

IV. Provider business mailing address

1497 WEST ELK AVE SUITE 21
ELIZABETHTON TN
37643
US

V. Phone/Fax

Practice location:
  • Phone: 423-542-7420
  • Fax: 423-542-7425
Mailing address:
  • Phone: 423-542-7420
  • Fax: 423-542-7425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CARL S KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-302-3051