=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730542473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2016
-----------------------------------------------------
Last Update Date | 03/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3175 LINDEN DR STE 3
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24202-5849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-258-4734
-----------------------------------------------------
Fax | 276-258-4736
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3175 LINDEN DR STE 3
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24202-5849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-258-4734
-----------------------------------------------------
Fax | 276-258-4736
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CARL STEVEN KILGORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-302-3051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS1201X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------