Healthcare Provider Details

I. General information

NPI: 1417683095
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPOARTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1980 HOLTON AVE E STE 103
BIG STONE GAP VA
24219-3367
US

IV. Provider business mailing address

509 MED TECH PKWY STE 100
JOHNSON CITY TN
37604-2579
US

V. Phone/Fax

Practice location:
  • Phone: 423-302-3480
  • Fax: 423-722-3009
Mailing address:
  • Phone: 423-302-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA TARTE
Title or Position: ENROLLMENT
Credential:
Phone: 423-302-6565