Healthcare Provider Details

I. General information

NPI: 1659475374
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 PAVILION DR
KINGSPORT TN
37660-4622
US

IV. Provider business mailing address

2300 PAVILION DR
KINGSPORT TN
37660-4622
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-5500
  • Fax: 423-392-5597
Mailing address:
  • Phone: 423-392-5500
  • Fax: 423-392-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: C. STEVEN KILGORE
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 423-915-5185