Healthcare Provider Details

I. General information

NPI: 1568705457
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 ONEEGA LN SUITE A
ERWIN TN
37650-2197
US

IV. Provider business mailing address

630 ONEEGA LN SUITE A
ERWIN TN
37650-2197
US

V. Phone/Fax

Practice location:
  • Phone: 423-735-5700
  • Fax: 423-735-0967
Mailing address:
  • Phone: 423-735-5700
  • Fax: 423-735-0967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CARL S KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5121