Healthcare Provider Details

I. General information

NPI: 1164966909
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 MEDICAL PARK DR SUITE E
MARION VA
24354-1100
US

IV. Provider business mailing address

245 MEDICAL PARK DR SUITE E
MARION VA
24354-1100
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-3600
  • Fax: 276-258-3605
Mailing address:
  • Phone: 276-258-3600
  • Fax: 276-258-3605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

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