Healthcare Provider Details

I. General information

NPI: 1689053753
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 W ELK AVE SUITE 20B
ELIZABETHTON TN
37643-2895
US

IV. Provider business mailing address

1497 W ELK AVE SUITE 20B
ELIZABETHTON TN
37643-2895
US

V. Phone/Fax

Practice location:
  • Phone: 423-232-6900
  • Fax: 423-232-6903
Mailing address:
  • Phone: 423-232-6900
  • Fax: 423-232-6903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: CARL STEVEN KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5116