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	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1982998852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Provider Business Mailing Address
First Line	:	7021 W LEE HIGHWAY
Second Line	:	SUITE B
City	:	RURAL RETREAT
State	:	VA
Zip	:	24368-0000
Country	:	US
Telephone Number	:	276-686-3067
Fax Number	:	276-686-2051

Provider Business Practice Location Address
First Line	:	7021 W LEE HIGHWAY
Second Line	:	SUITE B
City	:	RURAL RETREAT
State	:	VA
Zip	:	24368-0000
Country	:	US
Telephone Number	:	276-686-3067
Fax Number	:	276-686-2051

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CARL STEVEN KILGORE
Credential	:
Telephone Number	:	423-915-5116

Provider Enumeration Date	:	06/08/2011
Last Update Date	:	06/08/2011

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