Healthcare Provider Details

I. General information

NPI: 1568958775
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

408 N STATE OF FRANKLIN RD STE 31F
JOHNSON CITY TN
37604-6088
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 TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

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