Healthcare Provider Details

I. General information

NPI: 1205866092
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 GRAY COMMONS CIR SUITE B
GRAY TN
37615-5407
US

IV. Provider business mailing address

203 GRAY COMMONS CIR SUITE B
GRAY TN
37615-5407
US

V. Phone/Fax

Practice location:
  • Phone: 423-467-4802
  • Fax: 423-467-4801
Mailing address:
  • Phone: 423-467-4802
  • Fax: 423-467-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARL STEVEN KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5185