Healthcare Provider Details

I. General information

NPI: 1326058272
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

IV. Provider business mailing address

403 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-7047
  • Fax: 423-979-0569
Mailing address:
  • Phone: 423-431-7047
  • Fax: 423-979-0569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3377132
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 2
Identifier801453000
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerMAGELLAN
# 3
IdentifierCA5744
Identifier TypeOTHER
Identifier State
Identifier IssuerRR MEDICARE
# 4
Identifier1326058272
Identifier TypeMEDICAID
Identifier StateVA
Identifier Issuer
# 5
Identifier5908711
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

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