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NPI Code Detail

MEDICARE: BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

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
1363A00000XPhysician Assistant
2363L00000XNurse Practitioner
3363LF0000XFamily Nurse Practitioner
4363AM0700XMedical Physician Assistant
5207R00000XInternal Medicine Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
6CA5744OTHERTNRR MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14344805OTHERTNBLUECARE
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1275851974
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Provider Business Mailing Address
First Line : 509 MED TECH PKWY
Second Line : SUITE 100
City : JOHNSON CITY
State : TN
Zip : 37604-2578
Country : US
Telephone Number : 423-302-6882
Fax Number : 423-952-2147
Provider Business Practice Location Address
First Line : 300 MED TECH PKWY
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37604-2277
Country : US
Telephone Number : 423-431-1810
Fax Number : 423-431-1811
Authorized Official
Title or Position : PRESIDENT
Name : MR. CARL STEVEN KILGORE
Credential :
Telephone Number : 423-915-5100
Provider Enumeration Date : 05/06/2010
Last Update Date : 07/08/2015

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Directions to “BLUE RIDGE MEDICAL MANAGEMENT CORPORATION ” Practice Location

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