Healthcare Provider Details

I. General information

NPI: 1124472691
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 WHITE ST NE
ABINGDON VA
24210-2913
US

IV. Provider business mailing address

277 WHITE ST NE
ABINGDON VA
24210-2913
US

V. Phone/Fax

Practice location:
  • Phone: 276-628-4335
  • Fax: 276-628-3195
Mailing address:
  • Phone: 276-628-4335
  • Fax: 276-628-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: CARL STEVEN KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5121