Healthcare Provider Details

I. General information

NPI: 1063188365
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 TEMPLE HILL RD
ERWIN TN
37650-8721
US

IV. Provider business mailing address

1021 W OAKLAND AVE
JOHNSON CITY TN
37604-2191
US

V. Phone/Fax

Practice location:
  • Phone: 423-863-9147
  • Fax:
Mailing address:
  • Phone: 423-952-2111
  • Fax: 423-282-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LARAINE DOVER
Title or Position: DIRECTOR
Credential:
Phone: 423-952-2124