Healthcare Provider Details

I. General information

NPI: 1962434068
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 PRINCETON RD SUITE 7
JOHNSON CITY TN
37601-2026
US

IV. Provider business mailing address

311 PRINCETON RD SUITE 7
JOHNSON CITY TN
37601-2026
US

V. Phone/Fax

Practice location:
  • Phone: 423-282-3236
  • Fax: 423-283-4746
Mailing address:
  • Phone: 423-282-3236
  • Fax: 423-283-9430

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 Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CARL S KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5100