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	207Q00000X	Family Medicine Physician

Medicare Identifiers

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	623293300	OTHER	TN	DEPARTMENT OF LABOR
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730401209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Provider Business Mailing Address
First Line	:	2204 PAVILION DR
Second Line	:	SUITE 310
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4653
Country	:	US
Telephone Number	:	423-224-3900
Fax Number	:	423-224-3901

Provider Business Practice Location Address
First Line	:	2204 PAVILION DR
Second Line	:	SUITE 310
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4653
Country	:	US
Telephone Number	:	423-224-3900
Fax Number	:	423-224-3901

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CARL STEVE KILGORE
Credential	:
Telephone Number	:	423-302-3051

Provider Enumeration Date	:	02/24/2010
Last Update Date	:	03/29/2019

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Directions to “BLUE RIDGE MEDICAL MANAGEMENT CORPORATION ” Practice Location

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