Healthcare Provider Details

I. General information

NPI: 1740227131
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N STATE OF FRANKLIN RD SUITE 400
JOHNSON CITY TN
37604-6008
US

IV. Provider business mailing address

310 N STATE OF FRANKLIN RD SUITE 400
JOHNSON CITY TN
37604-6008
US

V. Phone/Fax

Practice location:
  • Phone: 423-979-6000
  • Fax: 423-979-6011
Mailing address:
  • Phone: 423-979-6000
  • Fax: 423-979-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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