Healthcare Provider Details

I. General information

NPI: 1093016024
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N STATE OF FRANKLIN RD SUITE 130
JOHNSON CITY TN
37604-6971
US

IV. Provider business mailing address

410 N STATE OF FRANKLIN RD SUITE 130
JOHNSON CITY TN
37604-6971
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 Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

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