Healthcare Provider Details

I. General information

NPI: 1962883678
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N STATE OF FRANKLIN RD SUITE 31B
JOHNSON CITY TN
37604-6089
US

IV. Provider business mailing address

408 N STATE OF FRANKLIN RD SUITE 31B
JOHNSON CITY TN
37604-6089
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-4946
  • Fax: 423-431-4947
Mailing address:
  • Phone: 423-431-4946
  • Fax: 423-431-4947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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