Healthcare Provider Details

I. General information

NPI: 1477055317
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16000 JOHNSTON MEMORIAL DR STE 309
ABINGDON VA
24211-7664
US

IV. Provider business mailing address

16000 JOHNSTON MEMORIAL DR STE 309
ABINGDON VA
24211-7664
US

V. Phone/Fax

Practice location:
  • Phone: 276-783-5400
  • Fax: 276-783-5521
Mailing address:
  • Phone: 276-783-5400
  • Fax: 276-783-5521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

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