Healthcare Provider Details

I. General information

NPI: 1316357593
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N STATE OF FRANKLIN RD SUITE 24 A
JOHNSON CITY TN
37604-6089
US

IV. Provider business mailing address

509 MED TECH PKWY SUITE 100
JOHNSON CITY TN
37604-2578
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-1810
  • Fax: 423-431-1811
Mailing address:
  • Phone: 423-302-6882
  • Fax: 423-952-2147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CARL STEVEN KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5100