Healthcare Provider Details

I. General information

NPI: 1386372993
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT C ORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N STATE OF FRANKLIN RD STE 31A
JOHNSON CITY TN
37604-6088
US

IV. Provider business mailing address

509 MED TECH PKWY STE 100
JOHNSON CITY TN
37604-2579
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-4946
  • Fax: 423-431-4947
Mailing address:
  • Phone: 423-302-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA TARTE
Title or Position: ENROLLMENT
Credential:
Phone: 423-302-6565