Healthcare Provider Details

I. General information

NPI: 1619263068
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16000 JOHNSTON MEMORIAL DR SUITE 313
ABINGDON VA
24211-7664
US

IV. Provider business mailing address

16000 JOHNSTON MEMORIAL DR SUITE 313
ABINGDON VA
24211-7664
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-3780
  • Fax: 276-258-3776
Mailing address:
  • Phone: 276-258-3780
  • Fax: 276-258-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101052144
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024166234
License Number StateVA

VIII. Authorized Official

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