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General NPI Number Information
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NPI Number | 1093016024
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
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Dates
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Enumeration Date | 11/08/2010
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Last Update Date | 03/28/2019
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Provider Practice Location Address
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Address Line | 410 N STATE OF FRANKLIN RD SUITE 130
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City | JOHNSON CITY
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State | TN
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Zip | 37604-6971
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Country | US
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Telephone | 423-431-2477
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Fax | 423-431-2478
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Provider Business Mailing Address
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Address Line | 410 N STATE OF FRANKLIN RD SUITE 130
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City | JOHNSON CITY
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State | TN
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Zip | 37604-6971
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Country | US
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Telephone | 423-431-2477
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Fax | 423-431-2478
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | CARL S KILGORE
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Credential |
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Telephone | 423-302-3051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number |
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License Number State |
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