Healthcare Provider Details

I. General information

NPI: 1811269640
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7021 WEST LEE HIGHWAY SUITE B
RURAL RETREAT VA
24368
US

IV. Provider business mailing address

7021 WEST LEE HIGHWAY SUITE B
RURAL RETREAT VA
24368
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 Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024166068
License Number StateVA

VIII. Authorized Official

Name: CARL STEVEN KILGORE
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5116