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	207RC0000X	Cardiovascular Disease Physician

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

General Provider Information

NPI Number	:	1346279486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Provider Business Mailing Address
First Line	:	1021 COOLIDGE ST
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37743-4672
Country	:	US
Telephone Number	:	423-636-2339
Fax Number	:	423-636-2430

Provider Business Practice Location Address
First Line	:	1021 COOLIDGE ST
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37743-4672
Country	:	US
Telephone Number	:	423-636-2339
Fax Number	:	423-636-2430

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	C STEVEN KILGORE
Credential	:
Telephone Number	:	423-915-5185

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	05/27/2010

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