Healthcare Provider Details

I. General information

NPI: 1215082730
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N STATE OF FRANKLIN RD SUITE 101
JOHNSON CITY TN
37604-6008
US

IV. Provider business mailing address

310 N STATE OF FRANKLIN RD SUITE 101
JOHNSON CITY TN
37604-6008
US

V. Phone/Fax

Practice location:
  • Phone: 423-929-7393
  • Fax: 423-929-0872
Mailing address:
  • Phone: 423-929-7393
  • Fax: 423-929-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular 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

VIII. Authorized Official

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