Healthcare Provider Details

I. General information

NPI: 1932617271
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPOARTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N STATE OF FRANKLIN RD STE 130
JOHNSON CITY TN
37604-6972
US

IV. Provider business mailing address

410 N STATE OF FRANKLIN RD STE 130
JOHNSON CITY TN
37604-6972
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-2477
  • Fax: 423-431-2478
Mailing address:
  • Phone: 423-431-2477
  • Fax: 423-431-2478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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