Provider Demographics
NPI:1548562267
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPOARTION
Entity type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPOARTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:619 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-3809
Mailing Address - Country:US
Mailing Address - Phone:276-258-3740
Mailing Address - Fax:276-258-3745
Practice Address - Street 1:619 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-3809
Practice Address - Country:US
Practice Address - Phone:276-258-3740
Practice Address - Fax:276-258-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1548562267Medicaid
VA622678800OtherDEPARTMENT OF LABOR
VA1548562267Medicaid