MEDICARE: BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RX0202X	Medical Oncology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CA5744	OTHER	TN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	020487822	OTHER	TN	DEPARTMENT OF LABOR

General Provider Information

NPI Number	:	1275761538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Provider Business Mailing Address
First Line	:	1 PROFESSIONAL PARK DR
Second Line	:	STE 21
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-6587
Country	:	US
Telephone Number	:	423-232-6900
Fax Number	:	423-232-6903

Provider Business Practice Location Address
First Line	:	1 PROFESSIONAL PARK DR
Second Line	:	STE 21
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-6587
Country	:	US
Telephone Number	:	423-232-6900
Fax Number	:	423-232-6903

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. CARL STEVEN KILGORE
Credential	:
Telephone Number	:	423-302-3051

Provider Enumeration Date	:	06/25/2009
Last Update Date	:	03/29/2019

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Directions to “BLUE RIDGE MEDICAL MANAGEMENT CORPORATION ” Practice Location

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