Organization
BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Active
Organization
BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Active
Other names
MSMG Extended Care JC
Organization subpart
No
Provider details
NPI number
Authorized official
CARL STEVEN KILGORE (PRESIDENT)
(423) 915-5100
Entity
Organization
Contact information
Practice address
408 N STATE OF FRANKLIN RD, SUITE 24 A, JOHNSON CITY, TN 37604-6089
(423) 431-1810
(423) 431-1811
Mailing address
509 MED TECH PKWY, SUITE 100, JOHNSON CITY, TN 37604-2578
(423) 302-6882
(423) 952-2147
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1316357593
—
VA
05
—
1534067
—
TN
Enumeration date
04/28/2014
Last updated
07/08/2015
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