Healthcare Provider Details

I. General information

NPI: 1417453440
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPOARTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MED TECH PKWY STE 300
JOHNSON CITY TN
37604-2365
US

IV. Provider business mailing address

701 MED TECH PKWY STE 300
JOHNSON CITY TN
37604-2365
US

V. Phone/Fax

Practice location:
  • Phone: 423-232-8301
  • Fax: 423-232-8304
Mailing address:
  • Phone: 423-232-8301
  • Fax: 423-232-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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