Provider Demographics
NPI:1669918314
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:2000 BROOKSIDE DR
Mailing Address - Street 2:1ST FLOOR ROOM 12
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4627
Mailing Address - Country:US
Mailing Address - Phone:423-857-5907
Mailing Address - Fax:423-857-5904
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:1ST FLOOR ROOM 12
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-5907
Practice Address - Fax:423-857-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ026077Medicaid
VA1669918314Medicaid