Healthcare Provider Details

I. General information

NPI: 1457795585
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16000 JOHNSTON MEMORIAL DR SUITE 213A
ABINGDON VA
24211-7659
US

IV. Provider business mailing address

16000 JOHNSTON MEMORIAL DR SUITE 213A
ABINGDON VA
24211-7659
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-1985
  • Fax: 276-258-1989
Mailing address:
  • Phone: 276-258-1985
  • Fax: 276-258-1989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: CARL STEVEN KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5116